Provider Demographics
NPI:1215307061
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:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-829-2791
Mailing Address - Street 1:195 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9572
Mailing Address - Country:US
Mailing Address - Phone:763-280-5711
Mailing Address - Fax:763-263-5822
Practice Address - Street 1:195 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-9572
Practice Address - Country:US
Practice Address - Phone:763-280-5711
Practice Address - Fax:763-263-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty