Provider Demographics
NPI:1952546160
Name:MODERN DENTAL PROFESSIONALS, MINNESOTA PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS, MINNESOTA PC
Other - Org Name:MIDWEST DENTAL - SOUTH ST. PAUL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROFESSIONAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:J
Authorized Official - Last Name:PELKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:680 SOUTHVIEW BLVD.
Mailing Address - Street 2:
Mailing Address - City:SOUTH ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075
Mailing Address - Country:US
Mailing Address - Phone:651-455-2297
Mailing Address - Fax:651-455-9223
Practice Address - Street 1:680 SOUTHVIEW BLVD.
Practice Address - Street 2:
Practice Address - City:SOUTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075
Practice Address - Country:US
Practice Address - Phone:651-455-2297
Practice Address - Fax:651-455-9223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty