Provider Demographics
NPI:1255639696
Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS MINNESOTA PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1121 TOWN CENTRE DR
Mailing Address - Street 2:#200
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1199
Mailing Address - Country:US
Mailing Address - Phone:651-454-4771
Mailing Address - Fax:651-406-9298
Practice Address - Street 1:1121 TOWN CENTRE DR
Practice Address - Street 2:#200
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1199
Practice Address - Country:US
Practice Address - Phone:651-454-4771
Practice Address - Fax:651-406-9298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty