Healthcare Provider Details

I. General information

NPI: 1912796004
Provider Name (Legal Business Name): MANMEET SANDHU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 W STOUT ST
RICE LAKE WI
54868-5001
US

IV. Provider business mailing address

1755 ERICKSON CIR
STOCKTON CA
95206-6314
US

V. Phone/Fax

Practice location:
  • Phone: 715-236-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113272
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001777-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: