Provider Demographics
NPI:1952907909
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 1:14401 ISSAQUAH HOBART RD SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-6925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14401 ISSAQUAH HOBART RD SE
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-6925
Practice Address - Country:US
Practice Address - Phone:425-369-6886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTLAND DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty