Provider Demographics
NPI:1710309075
Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Other - Org Name:MIDWEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
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 1:203 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELROSE
Mailing Address - State:MN
Mailing Address - Zip Code:56352-4524
Mailing Address - Country:US
Mailing Address - Phone:320-256-4267
Mailing Address - Fax:320-256-4167
Practice Address - Street 1:203 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MELROSE
Practice Address - State:MN
Practice Address - Zip Code:56352-4524
Practice Address - Country:US
Practice Address - Phone:320-256-4267
Practice Address - Fax:320-256-4167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty