Provider Demographics
NPI:1326260035
Name:LUBISICH, JOSEF W (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JOSEF
Middle Name:W
Last Name:LUBISICH
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SE 120TH AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4090
Mailing Address - Country:US
Mailing Address - Phone:360-256-1755
Mailing Address - Fax:360-882-8080
Practice Address - Street 1:300 SE 120TH AVE
Practice Address - Street 2:STE. 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4090
Practice Address - Country:US
Practice Address - Phone:360-256-1755
Practice Address - Fax:360-882-8080
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000100881223P0221X
ORD86811223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049481Medicaid
WA5049481Medicaid