Provider Demographics
NPI:1518006790
Name:HIBBS, AGNES MARY (DDS)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:MARY
Last Name:HIBBS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1362 WILLISTON ROAD
Mailing Address - Street 2:
Mailing Address - City:SO BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6416
Mailing Address - Country:US
Mailing Address - Phone:802-862-0927
Mailing Address - Fax:802-864-7071
Practice Address - Street 1:1362 WILLISTON ROAD
Practice Address - Street 2:
Practice Address - City:SO BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6416
Practice Address - Country:US
Practice Address - Phone:802-862-0927
Practice Address - Fax:802-864-7071
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT01600010031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1001646Medicaid