Provider Demographics
NPI:1346630910
Name:DAGRES, PAUL (CPHT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:DAGRES
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BURPEE RD
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-1736
Mailing Address - Country:US
Mailing Address - Phone:781-224-4001
Mailing Address - Fax:
Practice Address - Street 1:16 BURPEE RD
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-1736
Practice Address - Country:US
Practice Address - Phone:978-224-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPT7518183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0405914Medicaid