Healthcare Provider Details

I. General information

NPI: 1467799866
Provider Name (Legal Business Name): TC ORTHODONTICS RED WING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 W 4TH ST
RED WING MN
55066-2413
US

IV. Provider business mailing address

615 W 4TH ST
RED WING MN
55066-2413
US

V. Phone/Fax

Practice location:
  • Phone: 651-388-8851
  • Fax:
Mailing address:
  • Phone: 651-388-8851
  • 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 HOLLY KELLY
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 763-420-1030