Provider Demographics
NPI:1922713817
Name:ROBERT MONGRAIN, QUIRT, GIBREE, P.C.
Entity Type:Organization
Organization Name:ROBERT MONGRAIN, QUIRT, GIBREE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:1105 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3016
Practice Address - Country:US
Practice Address - Phone:360-916-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROBERT MONGRAIN, QUIRT, GIBREE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty