MEDICARE: PDG, PA

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1144780420
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PDG, PA

Provider Business Mailing Address
First Line	:	2200 COUNTY ROAD C W STE 2210
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-2551
Country	:	US
Telephone Number	:	651-746-2815
Fax Number	:

Provider Business Practice Location Address
First Line	:	906 WOODLAND AVE
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55812-1113
Country	:	US
Telephone Number	:	218-606-1040
Fax Number	:	218-606-1060

Authorized Official
Title or Position	:	CREDENTIALING SPECIALISTS
Name	:	SHANNON HESSE
Credential	:
Telephone Number	:	651-746-2815

Provider Enumeration Date	:	03/22/2019
Last Update Date	:	10/28/2020

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