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General NPI Number Information
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NPI Number | 1295965572
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL PROFESSIONALS, MN PC
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Dates
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Enumeration Date | 07/21/2009
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Last Update Date | 07/21/2009
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Provider Practice Location Address
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Address Line | 379 S MAIN ST
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City | ZUMBROTA
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State | MN
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Zip | 55992-1543
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Country | US
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Telephone | 507-732-5346
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Fax | 507-732-5655
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Provider Business Mailing Address
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Address Line | 379 S MAIN ST
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City | ZUMBROTA
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State | MN
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Zip | 55992-1543
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Country | US
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Telephone | 507-732-5346
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Fax | 507-732-5655
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Authorized Official
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Title or Position | CEO
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Name | DR. JEFFREY W. MOOS
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Credential | DDS
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Telephone | 715-926-5050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D11386
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License Number State | MN
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