MEDICARE: MODERN DENTAL PROFESSIONALS, MN 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	:	1558643817
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS, MN PC

Provider Business Mailing Address
First Line	:	4140 THIELMAN LN
Second Line	:	SUITE 302
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-7326
Country	:	US
Telephone Number	:	320-252-7752
Fax Number	:	320-252-2289

Provider Business Practice Location Address
First Line	:	4140 THIELMAN LN
Second Line	:	SUITE 302
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-7326
Country	:	US
Telephone Number	:	320-252-7752
Fax Number	:	320-252-2289

Authorized Official
Title or Position	:	CFO
Name	:	JAMES MYER
Credential	:
Telephone Number	:	715-926-5050

Provider Enumeration Date	:	09/13/2011
Last Update Date	:	09/13/2011

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