Provider Demographics
NPI:1518569086
Name:DENTAL PROFESSIONALS OF WASHINGTON QUIRT MONGRAIN GIBREE PC
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF WASHINGTON QUIRT MONGRAIN GIBREE PC
Other - Org Name:WILDERNESS DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:23818 225TH AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-5088
Mailing Address - Country:US
Mailing Address - Phone:425-358-2553
Mailing Address - Fax:
Practice Address - Street 1:23818 225TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5088
Practice Address - Country:US
Practice Address - Phone:425-358-2553
Practice Address - Fax:425-358-7092
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF WASHINGTON, QUIRT, MONGRAIN, GIBREE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-10
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty