Healthcare Provider Details

I. General information

NPI: 1285170464
Provider Name (Legal Business Name): PDG, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18230 ZANE ST NW
ELK RIVER MN
55330-4501
US

IV. Provider business mailing address

2200 COUNTY ROAD C W 2210
ROSEVILLE MN
55113-2550
US

V. Phone/Fax

Practice location:
  • Phone: 763-201-1313
  • Fax: 763-201-1314
Mailing address:
  • Phone: 651-746-2815
  • Fax: 651-209-6312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN GULON
Title or Position: PRESIDENT
Credential:
Phone: 651-633-0500