Provider Demographics
NPI:1114025293
Name:RISTUBEN, PETER (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:RISTUBEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1952
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-1952
Mailing Address - Country:US
Mailing Address - Phone:425-888-2684
Mailing Address - Fax:425-831-2118
Practice Address - Street 1:38475 SE RIVER ST
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-9658
Practice Address - Country:US
Practice Address - Phone:425-888-2684
Practice Address - Fax:425-831-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000063881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice