Healthcare Provider Details

I. General information

NPI: 1275716474
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6563 LAKETOWNE PL UNIT A
ALBERTVILLE MN
55301-4510
US

IV. Provider business mailing address

6563 LAKETOWNE PL UNIT A
ALBERTVILLE MN
55301-4510
US

V. Phone/Fax

Practice location:
  • Phone: 763-493-3600
  • Fax: 763-493-3602
Mailing address:
  • Phone: 763-493-3600
  • Fax: 763-493-3602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD11386
License Number StateMN

VIII. Authorized Official

Name: DR. JEFFREY WILLIAM MOOS
Title or Position: CEO
Credential: DDS
Phone: 715-926-5050