Provider Demographics
NPI:1215674163
Name:QUIRT, MONGRAIN, GIBREE PROFESSIONAL SERVICES, PC
Entity type:Organization
Organization Name:QUIRT, MONGRAIN, GIBREE PROFESSIONAL SERVICES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8306
Mailing Address - Street 1:5100 GROVE ST STE A
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5100 GROVE ST STE A
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4492
Practice Address - Country:US
Practice Address - Phone:360-659-6732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUIRT, MONGRAIN, GIBREE PROFESSIONAL SERVICES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-12
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty