Provider Demographics
NPI:1770939613
Name:MODERN DENTAL PROFESSIONALS, MN PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS, MN PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RYDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:20700 CHIPPENDALE AVE W
Mailing Address - Street 2:SUITE 10
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8207
Mailing Address - Country:US
Mailing Address - Phone:651-315-8229
Mailing Address - Fax:651-571-0142
Practice Address - Street 1:20700 CHIPPENDALE AVE W
Practice Address - Street 2:SUITE 10
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024-8207
Practice Address - Country:US
Practice Address - Phone:651-315-8229
Practice Address - Fax:651-571-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty