MEDICARE: DR. PETER LUBISICH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	4438	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3798	OTHER	WA	WDS ID
2	409293	OTHER	WA	UNITED CONCORDIA/TRICARE

General Provider Information

NPI Number	:	1396756029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER LUBISICH DDS

Provider Business Mailing Address
First Line	:	300 SE 120TH AVE STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-4067
Country	:	US
Telephone Number	:	360-256-1755
Fax Number	:	360-882-8080

Provider Business Practice Location Address
First Line	:	300 SE 120TH AVE STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-4067
Country	:	US
Telephone Number	:	360-256-1755
Fax Number	:	360-882-8080

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	07/08/2007

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