Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | DE00006346 | WA |
NPI | 1750334199 |
---|---|
Provider Name | Dr. Peter Forber Vanderven |
First Address | Federal Way, WA 98003-8722 |
Second Address | Federal Way, WA 98003-8722 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2006 |
Last Update Date | 14/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U54613 | (02) | WA |