Provider Demographics
NPI:1912228073
Name:LUBISICH & LUBISICH, PLLC
Entity Type:Organization
Organization Name:LUBISICH & LUBISICH, PLLC
Other - Org Name:VANCOUVER PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBISICH
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:360-256-1755
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA44381223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5049481Medicaid
WA5055413Medicaid
WA5046941Medicaid