Healthcare Provider Details

I. General information

NPI: 1386710499
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

12180 BUSINESS PARK BOULEVARD NORTH
CHAMPLIN MN
55316-3123
US

IV. Provider business mailing address

2100 COUNTY ROAD C W SUITE 2210
ROSEVILLE MN
55113-2501
US

V. Phone/Fax

Practice location:
  • Phone: 763-421-5206
  • Fax:
Mailing address:
  • Phone: 651-633-0500
  • Fax: 651-636-6350

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: 651-633-0500