Provider Demographics
NPI:1104566728
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:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:
Authorized Official - Last Name:THULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8946
Mailing Address - Street 1:4445 LACEY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4445 LACEY BLVD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5716
Practice Address - Country:US
Practice Address - Phone:360-491-2532
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:2022-03-31
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty