Provider Demographics
NPI:1699811463
Name:GAGNON, PAUL A (DMD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:A
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 1:1169 CALL CREEK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3077
Mailing Address - Country:US
Mailing Address - Phone:208-233-8620
Mailing Address - Fax:208-233-8620
Practice Address - Street 1:1169 CALL CREEK DR
Practice Address - Street 2:SUITE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3077
Practice Address - Country:US
Practice Address - Phone:208-233-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3946122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist