=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992428395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUIRT, MONGRAIN, GIBREE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2222 MERIDIAN AVE E STE C
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98371-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-952-6112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2222 MERIDIAN AVE E STE C
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98371-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-952-6112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIA TEAM
-----------------------------------------------------
Name | HILLARY THULL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------