Provider Demographics
NPI:1275802092
Name:MODJEAN, MARK JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:MODJEAN
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 1:7001 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3162
Mailing Address - Country:US
Mailing Address - Phone:612-866-3322
Mailing Address - Fax:
Practice Address - Street 1:7001 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-3162
Practice Address - Country:US
Practice Address - Phone:612-866-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist