Provider Demographics
NPI:1275821027
Name:SANBERG, ADAM EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:EDWARD
Last Name:SANBERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-2201
Mailing Address - Country:US
Mailing Address - Phone:309-734-8403
Mailing Address - Fax:
Practice Address - Street 1:225 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-2201
Practice Address - Country:US
Practice Address - Phone:309-734-8403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist