Healthcare Provider Details

I. General information

NPI: 1730539362
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS MINNESOTA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 BAKER PARK RD SUITE 1040
MAPLE PLAIN MN
55359-9851
US

IV. Provider business mailing address

1400 BAKER PARK RD SUITE 1040
MAPLE PLAIN MN
55359-9851
US

V. Phone/Fax

Practice location:
  • Phone: 763-402-7003
  • Fax: 763-447-3208
Mailing address:
  • Phone: 763-402-7003
  • Fax: 763-447-3208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

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