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General NPI Number Information
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NPI Number | 1730788498
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL PROFESSIONALS
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Dates
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Enumeration Date | 10/22/2020
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 676 COUNTY ROAD 10 NE
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City | BLAINE
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State | MN
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Zip | 55434-2329
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Country | US
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Telephone | 763-780-5007
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Fax |
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Provider Business Mailing Address
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Address Line | 676 COUNTY ROAD 10 NE
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City | BLAINE
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State | MN
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Zip | 55434-2329
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Country | US
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Telephone | 763-780-5007
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | BRENT ALTHOFF
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Credential |
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Telephone | 715-203-4689
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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 |
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License Number State |
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