=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609737733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL PROFESSIONALS OF WASHINGTON, QUIRT, MONGRAIN, GIBREE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2025
-----------------------------------------------------
Last Update Date | 11/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 N 56TH PL UNIT 150
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98642-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 564-236-2950
-----------------------------------------------------
Fax | 564-236-2065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 420 N 56TH PL UNIT 150
-----------------------------------------------------
City | RIDGEFIELD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98642-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 564-236-2950
-----------------------------------------------------
Fax | 564-236-2065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | HILLARY THULL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------