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General NPI Number Information
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NPI Number | 1679866735
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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 | 05/24/2011
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Last Update Date | 05/24/2011
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Provider Practice Location Address
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Address Line | 24 S OLIVE ST
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City | WACONIA
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State | MN
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Zip | 55387-1404
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Country | US
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Telephone | 952-442-2518
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Fax | 952-442-5040
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Provider Business Mailing Address
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Address Line | 24 S OLIVE ST
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City | WACONIA
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State | MN
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Zip | 55387-1404
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Country | US
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Telephone | 952-442-2518
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Fax | 952-442-5040
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Authorized Official
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Title or Position | PRESIDENT - 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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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