Provider Demographics
NPI:1821606724
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:
Other - Org Type:
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 1:9514 4TH ST NE UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-1937
Mailing Address - Country:US
Mailing Address - Phone:425-334-4001
Mailing Address - Fax:
Practice Address - Street 1:9514 4TH ST NE UNIT 102
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-1937
Practice Address - Country:US
Practice Address - Phone:425-334-4001
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:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty