Provider Demographics
NPI:1992863401
Name:PROFESSIONAL DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ASSOCIATES PC
Other - Org Name:JENSEN SHROYER ANDERSON PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:MATHEWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-796-3571
Mailing Address - Street 1:415 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2049
Mailing Address - Country:US
Mailing Address - Phone:231-796-3571
Mailing Address - Fax:231-796-2211
Practice Address - Street 1:415 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2049
Practice Address - Country:US
Practice Address - Phone:231-796-3571
Practice Address - Fax:231-796-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010194041223G0001X
MI29010101021223G0001X
MI29010169451223G0001X
MI29010194031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID8012370OtherBCBS
MI1883236OtherUNITED CONCORDIA
MID802980OtherBCBS
MID8012380OtherBCBS