Provider Demographics
NPI:1043807571
Name:PDG,P.A.
Entity Type:Organization
Organization Name:PDG,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:HESSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-746-2815
Mailing Address - Street 1:2200 COUNTY ROAD C W STE 2210
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2551
Mailing Address - Country:US
Mailing Address - Phone:651-633-0500
Mailing Address - Fax:
Practice Address - Street 1:3300 EDINBOROUGH WAY STE 210
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5958
Practice Address - Country:US
Practice Address - Phone:952-831-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty