Provider Demographics
NPI:1487805925
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:PROFESSIONAL SERVICES
Authorized Official - Prefix:MS
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 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:715-926-5050
Mailing Address - Fax:715-926-4269
Practice Address - Street 1:302 FIRE MONUMENT RD
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037-8350
Practice Address - Country:US
Practice Address - Phone:320-384-6118
Practice Address - Fax:320-384-6832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11386122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty