MEDICARE: MODERN DENTAL PROFESSIONALS MINNESOTA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1447860523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS MINNESOTA PC

Provider Business Mailing Address
First Line	:	2010 27TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-1108
Country	:	US
Telephone Number	:	612-336-8478
Fax Number	:

Provider Business Practice Location Address
First Line	:	2010 27TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-1108
Country	:	US
Telephone Number	:	612-336-8478
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	BRENT ALTHOFF
Credential	:
Telephone Number	:	715-203-4689

Provider Enumeration Date	:	08/04/2020
Last Update Date	:	08/04/2020

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