Provider Demographics
NPI:1275696387
Name:MOEN, ROLF P (DDS)
Entity Type:Individual
Prefix:
First Name:ROLF
Middle Name:P
Last Name:MOEN
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 1:402 JAMES STREET
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2965
Mailing Address - Country:US
Mailing Address - Phone:218-829-4243
Mailing Address - Fax:218-825-8102
Practice Address - Street 1:402 JAMES STREET
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2965
Practice Address - Country:US
Practice Address - Phone:218-829-4243
Practice Address - Fax:218-825-8102
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN05220700Medicaid