Provider Demographics
NPI:1760033807
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:DENTAL CARE OF EDMONDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TABATHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-6078
Mailing Address - Street 1:23805 HIGHWAY 99 STE 100
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-9204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23805 HIGHWAY 99 STE 100
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-9204
Practice Address - Country:US
Practice Address - Phone:425-778-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF WASHINGTON QUIRT MONGRAIN GIBREE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty