Healthcare Provider Details

I. General information

NPI: 1003174764
Provider Name (Legal Business Name): DENTALIGN P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7860 MAIN ST
MAPLE GROVE MN
55369
US

IV. Provider business mailing address

4630 EDGEBROOK PL
EDINA MN
55424
US

V. Phone/Fax

Practice location:
  • Phone: 763-420-1030
  • Fax:
Mailing address:
  • Phone: 612-701-0478
  • Fax: 763-450-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD11493
License Number StateMN

VIII. Authorized Official

Name: CHAD HOLLY KELLY
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 612-701-0478