Provider Demographics
NPI:1871546184
Name:MC-LL LLC
Entity type:Organization
Organization Name:MC-LL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:F
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-235-2900
Mailing Address - Street 1:PO BOX 19187
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99219
Mailing Address - Country:US
Mailing Address - Phone:509-926-5272
Mailing Address - Fax:509-926-4855
Practice Address - Street 1:21801 E COUNTRY VISTA DR
Practice Address - Street 2:STE 105
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:509-926-5272
Practice Address - Fax:509-926-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA84401223G0001X
WA88531223G0001X
WA109931223G0001X
WADE602402341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5055470Medicaid