Provider Demographics
NPI:1467799924
Name:DENTALIGN, PA
Entity Type:Organization
Organization Name:DENTALIGN, PA
Other - Org Name:TC ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:HOLLY
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-701-0478
Mailing Address - Street 1:4630 EDGEBROOK PLACE
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55424
Mailing Address - Country:US
Mailing Address - Phone:612-701-0478
Mailing Address - Fax:
Practice Address - Street 1:2999 COUNTY ROAD 42 W SUITE 138
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306
Practice Address - Country:US
Practice Address - Phone:952-892-3282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty