Provider Demographics
NPI:1710913157
Name:GRIMES, SUSAN ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ANN
Last Name:GRIMES
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 1:30 SHELBURNE SHOPPING PARK
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7488
Mailing Address - Country:US
Mailing Address - Phone:802-985-3500
Mailing Address - Fax:802-985-2979
Practice Address - Street 1:30 SHELBURNE SHOPPING PARK
Practice Address - Street 2:
Practice Address - City:SHELBURNE
Practice Address - State:VT
Practice Address - Zip Code:05482-7488
Practice Address - Country:US
Practice Address - Phone:802-983-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT 9661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002660Medicaid