Provider Demographics
NPI:1679853451
Name:MODERN DENTAL PROFESSIONALS, MN PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS, MN PC
Other - Org Name:MIDWEST DENTAL RENVILLE
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 1:680 HEHLI WAY
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1639
Mailing Address - Country:US
Mailing Address - Phone:320-329-8321
Mailing Address - Fax:
Practice Address - Street 1:107 DUPONT AVE NW
Practice Address - Street 2:
Practice Address - City:RENVILLE
Practice Address - State:MN
Practice Address - Zip Code:56284
Practice Address - Country:US
Practice Address - Phone:715-926-5050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty