NPIMap

Organization Active NPI

Professional Dental Associates PC

  • General Practice Dentistry
  • Baldwin, MI
National Provider Identifier
1154592285
Registry record updated Mar 17, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
10102 Issued in MI
Legal business name
PROFESSIONAL DENTAL ASSOCIATES PC
Practice address
888 Michigan Ave
Baldwin, MI 49304
Phone
(231) 745-7231
Fax
(231) 745-7246
NPI assigned
Mar 17, 2008
Last updated
Mar 17, 2008By the provider in NPPES
Organization subpart
Yes
Parent organization
PROFESSIONAL DENTAL ASSOCIATES PCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 17, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Kevin T Mathewson, DDSNPI 1912072919
Title
Dentist Owner
Phone
(231) 796-3571

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 16945 MI
General Practice Dentistry 1223G0001X 19296 MA
General Practice Dentistry 1223G0001X 10102 MI Primary

Addresses

Primary practice location

888 Michigan Ave
Baldwin, MI 49304

Mailing address

PO Box 152
888 Michigan Ave
Baldwin, MI 49304
Phone (231) 745-7231

Other identifiers 2

IdentifierTypeStateIssuer
8012380OtherMIBCBS
2007556OtherMIUCCI

Other names 1

  • Jensen Shroger Anderson PC Former legal business name

National Provider Directory

National Provider Directory
Tax ID family
Professional Dental Associates PC3 organizations share this tax ID, including this one
Part of
Professional Dental Associates PC

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

888 Michigan Ave
Baldwin, MI 49304
Phone (231) 745-7231

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1205712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1205712000000",
    "number": "1154592285",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 152",
            "address_2": "888 MICHIGAN AVE",
            "city": "BALDWIN",
            "state": "MI",
            "postal_code": "49304",
            "telephone_number": "231-745-7231",
            "fax_number": "231-745-7246"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "888 MICHIGAN AVE",
            "city": "BALDWIN",
            "state": "MI",
            "postal_code": "49304",
            "telephone_number": "231-745-7231",
            "fax_number": "231-745-7246"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ASSOCIATES PC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PROFESSIONAL DENTAL ASSOCIATES PC",
        "enumeration_date": "2008-03-17",
        "last_updated": "2008-03-17",
        "status": "A",
        "authorized_official_last_name": "MATHEWSON",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "DENTIST OWNER",
        "authorized_official_telephone_number": "231-796-3571",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "16945",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MA",
            "license": "19296",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "10102",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "8012380",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCCI",
            "identifier": "2007556",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jensen Shroger Anderson PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Baldwin, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.