Provider Demographics
NPI:1437895778
Name:QUIRT MONGRAIN GIBREE - MARYVILLE, PC
Entity Type:Organization
Organization Name:QUIRT MONGRAIN GIBREE - MARYVILLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8306
Mailing Address - Street 1:4445 LACEY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5716
Mailing Address - Country:US
Mailing Address - Phone:360-491-2532
Mailing Address - Fax:
Practice Address - Street 1:4445 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5716
Practice Address - Country:US
Practice Address - Phone:360-491-2532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUIRT MONGRAIN GIBREE - MARYVILLE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty