Healthcare Provider Details

I. General information

NPI: 1184288979
Provider Name (Legal Business Name): PDG, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2019
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4891 MILLER TRUCK HWY. SUITE 100
HERMANTOWN MN
55811
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 218-722-7770
  • Fax: 218-740-3234
Mailing address:
  • Phone: 651-746-2815
  • Fax:

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