Provider Demographics
NPI:1750550109
Name:PROFESSIONAL DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ASSOCIATES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MATHEWSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:989-382-7227
Mailing Address - Street 1:98 NORTHERN AVENUE
Mailing Address - Street 2:PO BOX 244
Mailing Address - City:BARRYTON
Mailing Address - State:MI
Mailing Address - Zip Code:49305
Mailing Address - Country:US
Mailing Address - Phone:989-382-7227
Mailing Address - Fax:989-382-7227
Practice Address - Street 1:98 NORTHERN AVENUE
Practice Address - Street 2:
Practice Address - City:BARRYTON
Practice Address - State:MI
Practice Address - Zip Code:49305
Practice Address - Country:US
Practice Address - Phone:989-382-7227
Practice Address - Fax:989-382-7227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI169451223G0001X
MA192961223G0001X
MI101021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8012370OtherBC BS