Dominic Joseph Gagnon, DDS
Individual provider Active NPI General Practice Dentistry · Staples, MN
NPI 1669760138 · NPPES record last updated Aug 4, 2018
Key facts
- NPI
- 1669760138
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- D12933 (MN)
- Practice address
- 616 4TH St NE
Staples, MN 56479 - Phone
- (218) 894-2201
- NPI assigned
- Jul 18, 2011
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20170303000612 | MN | Order and Referring Only - Dentist |
5395029714 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D12933 | MN | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Dominic Gagnon, D.D.S., P.L.L.C. | General Practice | Current | Accepting new patients |
| Lakeland Dental P.L.L.C. | General Practice | Current | Accepting new patients |
| Lakeland Dentists, P.L.L.C. | Current | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | D12933 | MN | Yes |
Addresses
Primary practice location
616 4TH St NE
Staples, MN 56479
Mailing address
616 4TH St NE
Staples, MN 56479-2273
Phone (218) 894-2201
Other providers in Staples, MN
- Jesse Fenstermacher
- Madecyn Caroline Franz
- David Allan Freeman
- Fresenius Medical Care Centracare Dialysis, LLC
- Mitchell Jonathan Fritz
- Luann Annette Gammon
- Shelby Ann Gawarecki
- Joseph James Gerhartz
- Micheal Ginder
- Robert Gonzalez Jr.
All providers in Staples, MN · General Practice Dentistry in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 4, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.