MEDICARE: DENTALIGN, P.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	11493	MN

General Provider Information

NPI Number	:	1760802722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTALIGN, P.A

Provider Business Mailing Address
First Line	:	4630 EDGEBROOK PL
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55424-1152
Country	:	US
Telephone Number	:	763-420-1030
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 W 78TH ST
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-4524
Country	:	US
Telephone Number	:	763-420-1030
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CHAD H KELLY
Credential	:	D.M.D
Telephone Number	:	763-420-1030

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	04/17/2014

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Directions to “DENTALIGN, P.A ” Practice Location

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