| NPI | 1003174764 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHAD HOLLY KELLY President 612-701-0478 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN D11493) |
| Enumeration Date | 2012-05-01 |
| Last Update Date | 2012-05-01 |