Provider Demographics
NPI:1154592285
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:231-796-3571
Mailing Address - Street 1:PO BOX 152
Mailing Address - Street 2:888 MICHIGAN AVE
Mailing Address - City:BALDWIN
Mailing Address - State:MI
Mailing Address - Zip Code:49304
Mailing Address - Country:US
Mailing Address - Phone:231-745-7231
Mailing Address - Fax:231-745-7246
Practice Address - Street 1:888 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:MI
Practice Address - Zip Code:49304
Practice Address - Country:US
Practice Address - Phone:231-745-7231
Practice Address - Fax:231-745-7246
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL DENTAL ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI169451223G0001X
MA192961223G0001X
MI101021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2007556OtherUCCI
MI8012380OtherBCBS