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Organization
PROFESSIONAL DENTAL ASSOCIATES PC
Active
Organization
PROFESSIONAL DENTAL ASSOCIATES PC
Active
Other names
Jensen Shroyer Anderson PC
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEVIN TODD MATHEWSON DDS (DENTIST OWNER)
(231) 796-3571
Entity
Organization
Contact information
Practice address
415 SOUTH STATE STREET, BIG RAPIDS, MI 49307-2049
(231) 796-3571
(231) 796-2211
Mailing address
415 SOUTH STATE STREET, BIG RAPIDS, MI 49307-2049
(231) 796-3571
(231) 796-2211
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
2901010102
MI
1223G0001X
General Practice Dentistry
Primary
2901016945
MI
1223G0001X
General Practice Dentistry
2901019403
MI
1223G0001X
General Practice Dentistry
2901019404
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1883236
UNITED CONCORDIA
MI
01
—
D8012370
BCBS
MI
01
—
D8012380
BCBS
MI
01
—
D802980
BCBS
MI
Enumeration date
12/05/2006
Last updated
08/22/2020
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