Provider Demographics
NPI:1043589484
Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Other - Org Name:MIDWEST DENTAL - CHISAGO CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:29663 GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-0339
Mailing Address - Country:US
Mailing Address - Phone:651-257-3639
Mailing Address - Fax:
Practice Address - Street 1:29663 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-0339
Practice Address - Country:US
Practice Address - Phone:651-257-3639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty