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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1821356502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS, MINNESOTA PC

Provider Business Mailing Address
First Line	:	3345 DAKOTA AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2039
Country	:	US
Telephone Number	:	952-929-9450
Fax Number	:	952-929-1095

Provider Business Practice Location Address
First Line	:	3345 DAKOTA AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-2039
Country	:	US
Telephone Number	:	952-929-9450
Fax Number	:	952-929-1095

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY W MOOS
Credential	:	DDS
Telephone Number	:	715-926-5050

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	05/01/2012

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