Provider Demographics
NPI:1851617229
Name:SANDBERG, MATTHEW (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SANDBERG
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 1:6535 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2016
Mailing Address - Country:US
Mailing Address - Phone:414-258-8190
Mailing Address - Fax:
Practice Address - Street 1:6535 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2016
Practice Address - Country:US
Practice Address - Phone:414-258-8190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-10
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI6664-15122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223D0001XDental ProvidersDentistDental Public Health