Healthcare Provider Details

I. General information

NPI: 1043124837
Provider Name (Legal Business Name): LISA GAGNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WESTMINSTER ST
LEWISTON ME
04240-3531
US

IV. Provider business mailing address

8 SAINT TEKAKWITHA DR
LEWISTON ME
04240-2456
US

V. Phone/Fax

Practice location:
  • Phone: 207-513-1111
  • Fax:
Mailing address:
  • Phone: 207-240-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2355
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: