Provider Demographics
NPI:1689122442
Name:PDG, PA
Entity type:Organization
Organization Name:PDG, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GULON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-633-0500
Mailing Address - Street 1:2200 COUNTY ROAD C W
Mailing Address - Street 2:#2210
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2550
Mailing Address - Country:US
Mailing Address - Phone:651-746-2815
Mailing Address - Fax:651-209-6312
Practice Address - Street 1:7501 80TH ST S
Practice Address - Street 2:#214
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-3020
Practice Address - Country:US
Practice Address - Phone:651-459-2300
Practice Address - Fax:651-458-1836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND8289261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental