Healthcare Provider Details

I. General information

NPI: 1871837708
Provider Name (Legal Business Name): DENTALIGN, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 EDGEBROOK PL
EDINA MN
55424-1152
US

IV. Provider business mailing address

10617 FRANCE AVENUE S
BLOOMINGTON MN
55431
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-1030
  • Fax: 730-420-5510
Mailing address:
  • Phone: 763-420-1030
  • Fax: 430-420-5510

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