MEDICARE: DR. SUSANNE T GRENNELL D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	34188	NY

General Provider Information

NPI Number	:	1013189711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSANNE T GRENNELL D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 153
Second Line	:
City	:	BILLINGS
State	:	NY
Zip	:	12510-0153
Country	:	US
Telephone Number	:	845-677-0313
Fax Number	:	845-677-1095

Provider Business Practice Location Address
First Line	:	2755 ROUTE 82
Second Line	:
City	:	PLEASANT VALLEY
State	:	NY
Zip	:	12569-5009
Country	:	US
Telephone Number	:	845-677-0313
Fax Number	:	845-677-1095

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2008
Last Update Date	:	04/02/2008

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