Provider Demographics
NPI:1568461994
Name:GAGNON, LAWRENCE PAUL (DMD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:PAUL
Last Name:GAGNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 NE 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1418
Mailing Address - Country:US
Mailing Address - Phone:503-281-0866
Mailing Address - Fax:503-281-0867
Practice Address - Street 1:1904 NE 45TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1418
Practice Address - Country:US
Practice Address - Phone:503-281-0866
Practice Address - Fax:503-281-0867
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR48251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice