Provider Demographics
NPI:1245413921
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: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 1:431 MAIN ST N
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHATFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55923-1176
Mailing Address - Country:US
Mailing Address - Phone:507-867-3550
Mailing Address - Fax:
Practice Address - Street 1:226 MAIN ST S
Practice Address - Street 2:
Practice Address - City:CHATFIELD
Practice Address - State:MN
Practice Address - Zip Code:55923-1225
Practice Address - Country:US
Practice Address - Phone:507-867-3550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty