Healthcare Provider Details

I. General information

NPI: 1023549615
Provider Name (Legal Business Name): GAGNON DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MERRILL ST
FARMINGDALE ME
04344-1622
US

IV. Provider business mailing address

14 MERRILL ST
FARMINGDALE ME
04344-1622
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3738
License Number StateME

VIII. Authorized Official

Name: NATHAN CURTIS
Title or Position: MANAGER
Credential:
Phone: 207-626-3091