Provider Demographics
NPI:1710357520
Name:MODERN DENTAL PROFESSIONALS, MN PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS, MN PC
Other - Org Name:MIDWEST DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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:715-829-2791
Mailing Address - Street 1:1625 LENA CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2959
Mailing Address - Country:US
Mailing Address - Phone:651-452-4111
Mailing Address - Fax:651-452-8824
Practice Address - Street 1:1625 LENA CT
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2959
Practice Address - Country:US
Practice Address - Phone:651-452-4111
Practice Address - Fax:651-452-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty