MEDICARE: DENTAL PROFESSIONALS OF WASHINGTON QUIRT MONGRAIN GIBREE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1538631783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL PROFESSIONALS OF WASHINGTON QUIRT MONGRAIN GIBREE PC

Provider Business Mailing Address
First Line	:	3926 CLEVELAND AVE SE
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98501-4023
Country	:	US
Telephone Number	:	360-754-6072
Fax Number	:

Provider Business Practice Location Address
First Line	:	3926 CLEVELAND AVE SE
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98501-4023
Country	:	US
Telephone Number	:	360-754-6072
Fax Number	:

Authorized Official
Title or Position	:	CRED COR
Name	:	BRITTANY HOWARD
Credential	:
Telephone Number	:	217-540-8946

Provider Enumeration Date	:	12/28/2018
Last Update Date	:	12/28/2018

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