Provider Demographics
NPI:1548716830
Name:SNOQUALMIE FAMILY DENTISTRY
Entity type:Organization
Organization Name:SNOQUALMIE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:RISTUBEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:425-888-2684
Mailing Address - Street 1:PO BOX 1974
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-1974
Mailing Address - Country:US
Mailing Address - Phone:425-888-2684
Mailing Address - Fax:425-831-2119
Practice Address - Street 1:38475 SE RIVER STREET
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065
Practice Address - Country:US
Practice Address - Phone:425-888-2684
Practice Address - Fax:425-831-2119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00006388261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental