Healthcare Provider Details

I. General information

NPI: 1700810389
Provider Name (Legal Business Name): SHANNA LEIGH GAGNON D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MERRILL ST
FARMINGDALE ME
04344-1622
US

IV. Provider business mailing address

85 STONEHAM DR.
W. GARDINER ME
04345-7515
US

V. Phone/Fax

Practice location:
  • Phone: 207-626-3091
  • Fax: 207-622-5499
Mailing address:
  • Phone: 207-582-8358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3738
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: