Provider Demographics
NPI:1942978986
Name:GIBREE, QUIRT, MONGRAIN, P.C.
Entity Type:Organization
Organization Name:GIBREE, QUIRT, MONGRAIN, P.C.
Other - Org Name:SOUTHPOINT DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:1129 S 2ND AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1129 S 2ND AVE STE A
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4100
Practice Address - Country:US
Practice Address - Phone:509-522-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBREE, QUIRT, MONGRAIN, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-03
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty