Provider Demographics
NPI:1306970801
Name:GHATTAS, PETER NABEGH N (DPD)
Entity type:Individual
Prefix:
First Name:PETER NABEGH
Middle Name:N
Last Name:GHATTAS
Suffix:
Gender:M
Credentials:DPD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 E MAIN
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3167
Mailing Address - Country:US
Mailing Address - Phone:253-770-7707
Mailing Address - Fax:253-770-8784
Practice Address - Street 1:2811 E MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3167
Practice Address - Country:US
Practice Address - Phone:253-770-7707
Practice Address - Fax:253-770-8784
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000199122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5027412Medicaid