Provider Demographics
NPI:1750334199
Name:VANDERVEN, PETER FORBER (PLLC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:FORBER
Last Name:VANDERVEN
Suffix:
Gender:M
Credentials:PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34709 9TH AVE S
Mailing Address - Street 2:SUITE B-300
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8722
Mailing Address - Country:US
Mailing Address - Phone:253-874-2583
Mailing Address - Fax:253-874-8957
Practice Address - Street 1:34709 9TH AVE S
Practice Address - Street 2:SUITE B-300
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8722
Practice Address - Country:US
Practice Address - Phone:253-874-2583
Practice Address - Fax:253-874-8957
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000063461223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8860157Medicare PIN
WAU54613Medicare UPIN