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General NPI Number Information
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NPI Number | 1285029652
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Entity Type | Organization
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Legal Business Name | SANDBERG MODERN DENTAL LLC
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Dates
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Enumeration Date | 04/02/2015
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Last Update Date | 04/02/2015
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Provider Practice Location Address
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Address Line | 6535 W NORTH AVE
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City | WAUWATOSA
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State | WI
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Zip | 53213-2016
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Country | US
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Telephone | 414-258-8190
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Fax |
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Provider Business Mailing Address
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Address Line | 6535 W NORTH AVE
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City | WAUWATOSA
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State | WI
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Zip | 53213-2016
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Country | US
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Telephone | 414-258-8190
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MATTHEW SANDBERG
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Credential | DMD
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Telephone | 414-258-8190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | WI 6664-15
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License Number State | WI
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