Healthcare Provider Details

I. General information

NPI: 1538140934
Provider Name (Legal Business Name): MARK J MODJEAN DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 NICOLLET AVE S
RICHFIELD MN
55423-3162
US

IV. Provider business mailing address

7001 NICOLLET AVE S
RICHFIELD MN
55423-3162
US

V. Phone/Fax

Practice location:
  • Phone: 612-866-3322
  • Fax:
Mailing address:
  • Phone: 612-866-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8439
License Number StateMN

VIII. Authorized Official

Name: DR. MARK JOHN MODJEAN
Title or Position: PRES
Credential: DDS
Phone: 612-866-3322