Provider Demographics
NPI:1538886452
Name:MONGRAIN, QUIRT, GIBREE PROFESSIONAL SERVICES, P.C.
Entity type:Organization
Organization Name:MONGRAIN, QUIRT, GIBREE PROFESSIONAL SERVICES, 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 1:217 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3002
Mailing Address - Country:US
Mailing Address - Phone:509-525-7250
Mailing Address - Fax:
Practice Address - Street 1:217 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3002
Practice Address - Country:US
Practice Address - Phone:509-525-7250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONGRAIN, QUIRT, GIBREE PROFESSIONAL SERVICES, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty