Provider Demographics
NPI:1538140934
Name:MARK J MODJEAN DDS PA
Entity Type:Organization
Organization Name:MARK J MODJEAN DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MODJEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-866-3322
Mailing Address - Street 1:7001 NICOLLET AVE S
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 S
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8439122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty