Provider Demographics
NPI:1912072919
Name:MATHEWSON, KEVIN TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TODD
Last Name:MATHEWSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010-169451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3317643OtherMEDICAID
MI3272864Medicaid
MID169450OtherBCBS
MI971753OtherUNITED CONCORDIA