Provider Demographics
NPI:1558643817
Name:MODERN DENTAL PROFESSIONALS, MN PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS, MN PC
Other - Org Name:MIDWEST DENTAL - ST. CLOUD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:4140 THIELMAN LN
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-7326
Mailing Address - Country:US
Mailing Address - Phone:320-252-7752
Mailing Address - Fax:320-252-2289
Practice Address - Street 1:4140 THIELMAN LN
Practice Address - Street 2:SUITE 302
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-7326
Practice Address - Country:US
Practice Address - Phone:320-252-7752
Practice Address - Fax:320-252-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty