1710763784 NPI number — DENTAL PROFESSIONALS OF WASHINGTON, QUIRT, MONGRAIN, GIBREE, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710763784 NPI number — DENTAL PROFESSIONALS OF WASHINGTON, QUIRT, MONGRAIN, GIBREE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL PROFESSIONALS OF WASHINGTON, QUIRT, MONGRAIN, GIBREE, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710763784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17513 CANYON PKWY E STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98446-7500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-330-8960
Provider Business Mailing Address Fax Number:
253-330-8938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17513 CANYON PKWY E STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98446-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-330-8960
Provider Business Practice Location Address Fax Number:
253-330-8938
Provider Enumeration Date:
09/06/2023

Additional Information

Authorized Official

Authorized Official Last Name:
HUERTA
Authorized Official First Name:
BELINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
217-540-2100

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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