Provider Demographics
NPI:1275716474
Name:MODERN DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS
Other - Org Name:MIDWEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:6563 LAKETOWNE PL
Mailing Address - Street 2:UNIT A
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-4510
Mailing Address - Country:US
Mailing Address - Phone:763-493-3600
Mailing Address - Fax:763-493-3602
Practice Address - Street 1:6563 LAKETOWNE PL
Practice Address - Street 2:UNIT A
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-4510
Practice Address - Country:US
Practice Address - Phone:763-493-3600
Practice Address - Fax:763-493-3602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty