Provider Demographics
NPI:1992786966
Name:SALLBERG, PHILIP BRUCE (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:BRUCE
Last Name:SALLBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CENTER ST W
Mailing Address - Street 2:
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1419
Mailing Address - Country:US
Mailing Address - Phone:218-463-1070
Mailing Address - Fax:218-463-1170
Practice Address - Street 1:308 CENTER ST W
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1419
Practice Address - Country:US
Practice Address - Phone:218-463-1070
Practice Address - Fax:218-463-1170
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8357122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist