Provider Demographics
NPI:1730539362
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:PC OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:1400 BAKER PARK RD
Mailing Address - Street 2:SUITE 1040
Mailing Address - City:MAPLE PLAIN
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9851
Mailing Address - Country:US
Mailing Address - Phone:763-402-7003
Mailing Address - Fax:763-447-3208
Practice Address - Street 1:1400 BAKER PARK RD
Practice Address - Street 2:SUITE 1040
Practice Address - City:MAPLE PLAIN
Practice Address - State:MN
Practice Address - Zip Code:55359-9851
Practice Address - Country:US
Practice Address - Phone:763-402-7003
Practice Address - Fax:763-447-3208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty