Healthcare Provider Details

I. General information

NPI: 1841366093
Provider Name (Legal Business Name): PDG, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14990 GLAZIER AVE SUITE 100
APPLE VALLEY MN
55124-7818
US

IV. Provider business mailing address

3030 CENTRE POINTE DR SUITE 100
ROSEVILLE MN
55113-1112
US

V. Phone/Fax

Practice location:
  • Phone: 952-431-5114
  • Fax:
Mailing address:
  • Phone: 651-286-8100
  • Fax: 651-633-6811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN GULON
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 952-949-2536