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NPI Code Detail

MEDICARE: PDG,P.A.

MEDICARE: PDG,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
11223G0001XGeneral Practice Dentistry

General Provider Information

NPI Number : 1518033695
Entity Type Code : Organization
Provider Name (Legal Business Name) : PDG,P.A.
Provider Business Mailing Address
First Line : 2200 COUNTY ROAD C W
Second Line : SUITE 2210
City : ROSEVILLE
State : MN
Zip : 55113-2504
Country : US
Telephone Number : 651-633-0500
Fax Number : 651-636-6350
Provider Business Practice Location Address
First Line : 6437 BROOKLYN BLVD
Second Line :
City : BROOKLYN CENTER
State : MN
Zip : 55429-2174
Country : US
Telephone Number : 763-531-7177
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. JOHN GULON
Credential : D.D.S.
Telephone Number : 651-633-0500
Provider Enumeration Date : 11/28/2006
Last Update Date : 10/28/2020

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