Healthcare Provider Details

I. General information

NPI: 1760802722
Provider Name (Legal Business Name): DENTALIGN, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 W 78TH ST
CHANHASSEN MN
55317-4524
US

IV. Provider business mailing address

4630 EDGEBROOK PL
EDINA MN
55424-1152
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-1030
  • Fax:
Mailing address:
  • Phone: 763-420-1030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11493
License Number StateMN

VIII. Authorized Official

Name: DR. CHAD H KELLY
Title or Position: PRESIDENT
Credential: D.M.D
Phone: 763-420-1030