Provider Demographics
NPI:1164462487
Name:MC-NSPK LLC
Entity Type:Organization
Organization Name:MC-NSPK LLC
Other - Org Name:MINT CONDITION DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:F
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-235-2900
Mailing Address - Street 1:PO BOX 19187
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99219-9187
Mailing Address - Country:US
Mailing Address - Phone:509-489-4763
Mailing Address - Fax:509-489-4767
Practice Address - Street 1:5901 N. LIDGERWOOD
Practice Address - Street 2:STE 233
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-489-4763
Practice Address - Fax:509-489-4767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60240234122300000X
WA88531223G0001X
WA84401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5031968Medicaid