Provider Demographics
NPI:1710755590
Name:GANNETT DRIVE DENTAL PLLC
Entity Type:Organization
Organization Name:GANNETT DRIVE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-387-5658
Mailing Address - Street 1:10 SUSAN AVE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9726
Mailing Address - Country:US
Mailing Address - Phone:603-387-5658
Mailing Address - Fax:
Practice Address - Street 1:324 GANNETT DR STE 500
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3361
Practice Address - Country:US
Practice Address - Phone:207-253-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental