=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770939613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN DENTAL PROFESSIONALS, MN PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2016
-----------------------------------------------------
Last Update Date | 05/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20700 CHIPPENDALE AVE W SUITE 10
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55024-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-315-8229
-----------------------------------------------------
Fax | 651-571-0142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20700 CHIPPENDALE AVE W SUITE 10
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55024-8207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-315-8229
-----------------------------------------------------
Fax | 651-571-0142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | ELIZABETH RYDELL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 715-926-5050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------