Provider Demographics
NPI:1588186662
Name:GRIMES, ELLEN B (RDH, EDD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:B
Last Name:GRIMES
Suffix:
Gender:F
Credentials:RDH, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-9200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 LAWRENCE PLACE
Practice Address - Street 2:VERMONT TECHNICAL COLLEGE
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495
Practice Address - Country:US
Practice Address - Phone:802-879-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT015.0000919124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist