Provider Demographics
NPI:1679866735
Name:MODERN DENTAL PROFESSIONALS MN PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS MN PC
Other - Org Name:MIDWEST DENTAL - WACONIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT - CEO
Authorized Official - Prefix:DR
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 1:24 S OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1404
Mailing Address - Country:US
Mailing Address - Phone:952-442-2518
Mailing Address - Fax:952-442-5040
Practice Address - Street 1:24 S OLIVE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1404
Practice Address - Country:US
Practice Address - Phone:952-442-2518
Practice Address - Fax:952-442-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty