MEDICARE: MODERN DENTAL PROFESSIONALS, MINNESOTA PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1023250503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS, MINNESOTA PC

Provider Business Mailing Address
First Line	:	680 HEHLI WAY
Second Line	:
City	:	MONDOVI
State	:	WI
Zip	:	54755-1639
Country	:	US
Telephone Number	:	715-926-5050
Fax Number	:	715-926-4269

Provider Business Practice Location Address
First Line	:	931 WHITEWATER AVE
Second Line	:
City	:	SAINT CHARLES
State	:	MN
Zip	:	55972-1130
Country	:	US
Telephone Number	:	507-932-4530
Fax Number	:

Authorized Official
Title or Position	:	PROFESSIONAL SERVICES COORDINATOR
Name	:	LORI PELKE
Credential	:
Telephone Number	:	715-926-5050

Provider Enumeration Date	:	03/31/2009
Last Update Date	:	03/31/2009

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