Provider Demographics
NPI:1760703821
Name:LUBISICH, PETER IV (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LUBISICH
Suffix:IV
Gender:M
Credentials:DMD
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:SUITE 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:SUITE 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:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000097241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE00009724OtherSTATE LICENSE
WA5046941Medicaid