Healthcare Provider Details

I. General information

NPI: 1609938976
Provider Name (Legal Business Name): JOHN D. GAGNON DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 N RIDGE RD SUITE 500
WICHITA KS
67205-1224
US

IV. Provider business mailing address

3510 N RIDGE RD SUITE 500
WICHITA KS
67205-1224
US

V. Phone/Fax

Practice location:
  • Phone: 316-722-0800
  • Fax: 316-722-5822
Mailing address:
  • Phone: 316-722-0800
  • Fax: 316-722-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6850
License Number StateKS

VIII. Authorized Official

Name: JOHN D GAGNON
Title or Position: OWNER
Credential: DDS
Phone: 316-722-0800