Provider Demographics
NPI:1720036221
Name:GRIMES, WENDELL ELLIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:ELLIS
Last Name:GRIMES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3141 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-2801
Mailing Address - Country:US
Mailing Address - Phone:225-775-1388
Mailing Address - Fax:225-775-1344
Practice Address - Street 1:1806 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-2842
Practice Address - Country:US
Practice Address - Phone:225-775-1388
Practice Address - Fax:225-775-1344
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4696122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist