Provider Demographics
NPI:1316216377
Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Other - Org Name:MIDWEST DENTAL - WELLS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:150 3RD ST NW
Mailing Address - Street 2:
Mailing Address - City:WELLS
Mailing Address - State:MN
Mailing Address - Zip Code:56097-1021
Mailing Address - Country:US
Mailing Address - Phone:507-553-5085
Mailing Address - Fax:507-553-5948
Practice Address - Street 1:150 3RD ST NW
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:MN
Practice Address - Zip Code:56097-1021
Practice Address - Country:US
Practice Address - Phone:507-553-5085
Practice Address - Fax:507-553-5948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty