Provider Demographics
NPI:1306998893
Name:GRIMES, LISA RENEE (DDS)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
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 1:2020 INDIAN DR
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-6711
Mailing Address - Country:US
Mailing Address - Phone:580-242-3736
Mailing Address - Fax:
Practice Address - Street 1:1204 W WILLOW RD
Practice Address - Street 2:STE. C
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2531
Practice Address - Country:US
Practice Address - Phone:580-233-1427
Practice Address - Fax:580-233-1423
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5575122300000X
KY102141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100043850AMedicaid