Healthcare Provider Details

I. General information

NPI: 1508775586
Provider Name (Legal Business Name): KATHRYN RISTUBEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 SE 34TH ST
MERCER ISLAND WA
98040-3022
US

IV. Provider business mailing address

8220 SE 34TH ST
MERCER ISLAND WA
98040-3022
US

V. Phone/Fax

Practice location:
  • Phone: 425-922-1080
  • Fax:
Mailing address:
  • Phone: 425-922-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.70150859
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: