Provider Demographics
NPI:1952143109
Name:MOEN, MATTHEW JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JAMES
Last Name:MOEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18753 MELROSE CHASE
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-3483
Mailing Address - Country:US
Mailing Address - Phone:612-590-6448
Mailing Address - Fax:
Practice Address - Street 1:14741 VICTOR HUGO BLVD N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-4561
Practice Address - Country:US
Practice Address - Phone:651-407-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15093122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist