Provider Demographics
NPI:1104201284
Name:PDG, PA
Entity Type:Organization
Organization Name:PDG, PA
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 1:1835 COUNTY ROAD C W
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-209-7088
Practice Address - Fax:651-636-1118
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PDG, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-30
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental