MEDICARE: GANNETT DRIVE DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1710755590
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GANNETT DRIVE DENTAL PLLC

Provider Business Mailing Address
First Line	:	10 SUSAN AVE
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-9726
Country	:	US
Telephone Number	:	603-387-5658
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 GANNETT DR STE 500
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-3361
Country	:	US
Telephone Number	:	207-253-5600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER GAGNON
Credential	:	DMD
Telephone Number	:	603-387-5658

Provider Enumeration Date	:	12/12/2023
Last Update Date	:	12/12/2023

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