Provider Demographics
NPI:1083762041
Name:PDG,P.A.
Entity Type:Organization
Organization Name:PDG,P.A.
Other - Org Name:FACIAL PAIN CENTER
Other - Org Type:Doing Business As
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:DDS
Authorized Official - Phone:651-633-0500
Mailing Address - Street 1:2200 COUNTY ROAD C W
Mailing Address - Street 2:SUITE 2210
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2550
Mailing Address - Country:US
Mailing Address - Phone:651-633-0500
Mailing Address - Fax:651-636-6350
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE 366
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:952-926-3858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PDG, P.A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-08
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty