Provider Demographics
NPI:1710358379
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 1:7532 BROOKLYN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3101
Mailing Address - Country:US
Mailing Address - Phone:763-280-5737
Mailing Address - Fax:763-560-1625
Practice Address - Street 1:7532 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3101
Practice Address - Country:US
Practice Address - Phone:763-280-5737
Practice Address - Fax:763-560-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty