Healthcare Provider Details

I. General information

NPI: 1598300675
Provider Name (Legal Business Name): DENTALIGN, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11942 BUSINESS PARK BLVD
CHAMPLIN MN
55316
US

IV. Provider business mailing address

4630 EDGEBROOK PLACE
EDINA MN
55424
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-9131
  • Fax:
Mailing address:
  • Phone: 612-701-0478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHAD KELLY
Title or Position: PRESIDENT
Credential: DMD
Phone: 763-420-1030