Provider Demographics
NPI:1639509334
Name:PDG, P.A.
Entity Type:Organization
Organization Name:PDG, P.A.
Other - Org Name:PARK DENTAL
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:
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 1:11240 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9321
Practice Address - Country:US
Practice Address - Phone:651-777-0210
Practice Address - Fax:651-777-0320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-15
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental