Healthcare Provider Details

I. General information

NPI: 1043807571
Provider Name (Legal Business Name): PDG,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 12/30/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 EDINBOROUGH WAY STE 210
EDINA MN
55435-5958
US

IV. Provider business mailing address

2200 COUNTY ROAD C W STE 2210
ROSEVILLE MN
55113-2551
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-1112
  • Fax:
Mailing address:
  • Phone: 651-633-0500
  • Fax:

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: SHANNON HESSE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 651-746-2815