# PROFESSIONAL DENTAL ASSOCIATES PC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** PROFESSIONAL DENTAL ASSOCIATES PC
- **Other names:** Jensen Shroger Anderson PC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1154592285
- **Legal business name:** PROFESSIONAL DENTAL ASSOCIATES PC
- **Authorized official:** DR. KEVIN T MATHEWSON DDS (DENTIST OWNER)
- **Authorized official phone:** (231) 796-3571

## Contact information

- **Practice address:** 888 MICHIGAN AVE, BALDWIN, MI 49304
- **Practice address phone:** (231) 745-7231
- **Practice address fax:** (231) 745-7246
- **Mailing address:** PO BOX 152, 888 MICHIGAN AVE, BALDWIN, MI 49304
- **Mailing address phone:** (231) 745-7231
- **Mailing address fax:** (231) 745-7246

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 10102 | MI | Yes |
| 1223G0001X | General Practice Dentistry | 16945 | MI | — |
| 1223G0001X | General Practice Dentistry | 19296 | MA | — |

## Other

- **Enumeration date:** 03/17/2008
- **Last updated:** 03/17/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2007556 | UCCI | MI |
| 01 | — | 8012380 | BCBS | MI |