Provider Demographics
NPI:1235509084
Name:MODERN DENTAL PROFESSIONALS MN PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS MN PC
Other - Org Name:MIDWEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-829-2791
Mailing Address - Street 1:15594 PILOT KNOB RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7295
Mailing Address - Country:US
Mailing Address - Phone:651-419-3840
Mailing Address - Fax:952-423-1978
Practice Address - Street 1:15594 PILOT KNOB RD
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7295
Practice Address - Country:US
Practice Address - Phone:651-419-3840
Practice Address - Fax:952-423-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty