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General NPI Number Information
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NPI Number | 1912228073
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Entity Type | Organization
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Legal Business Name | LUBISICH & LUBISICH, PLLC
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Dates
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Enumeration Date | 06/11/2010
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Last Update Date | 06/11/2010
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Provider Practice Location Address
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Address Line | 300 SE 120TH AVE SUITE 100
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City | VANCOUVER
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State | WA
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Zip | 98683-4090
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Country | US
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Telephone | 360-256-1755
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Fax | 360-882-8080
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Provider Business Mailing Address
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Address Line | 300 SE 120TH AVE SUITE 100
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City | VANCOUVER
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State | WA
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Zip | 98683-4090
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Country | US
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Telephone | 360-256-1755
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Fax | 360-882-8080
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Authorized Official
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Title or Position | OWNER
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Name | PETER LUBISICH IV
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Credential |
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Telephone | 360-256-1755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 4438
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License Number State | WA
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