Provider Demographics
NPI:1295238178
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:DIRECTOR, PAYER STRATEGY
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-351-6876
Mailing Address - Street 1:680 HEHLI WAY
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1639
Mailing Address - Country:US
Mailing Address - Phone:715-598-2311
Mailing Address - Fax:715-350-6855
Practice Address - Street 1:4520 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-3602
Practice Address - Country:US
Practice Address - Phone:651-426-4799
Practice Address - Fax:651-426-8106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty