Healthcare Provider Details

I. General information

NPI: 1871546184
Provider Name (Legal Business Name): MC-LL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21801 E COUNTRY VISTA DR STE 105
LIBERTY LAKE WA
99019
US

IV. Provider business mailing address

PO BOX 19187
SPOKANE WA
99219
US

V. Phone/Fax

Practice location:
  • Phone: 509-926-5272
  • Fax: 509-926-4855
Mailing address:
  • Phone: 509-926-5272
  • Fax: 509-926-4855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8853
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10993
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60240234
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8440
License Number StateWA

VIII. Authorized Official

Name: MR. MARSHALL F GIBBS
Title or Position: OWNER
Credential: DDS
Phone: 509-235-2900