Healthcare Provider Details

I. General information

NPI: 1992786966
Provider Name (Legal Business Name): PHILIP BRUCE SALLBERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CENTER ST W
ROSEAU MN
56751-1419
US

IV. Provider business mailing address

308 CENTER ST W
ROSEAU MN
56751-1419
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-1070
  • Fax: 218-463-1170
Mailing address:
  • Phone: 218-463-1070
  • Fax: 218-463-1170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8357
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: