NPIMap

Organization Active NPI

Professional Dental Associates PC

  • General Practice Dentistry
  • Barryton, MI
National Provider Identifier
1750550109
Registry record updated Feb 29, 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
98 Northern Avenue
Barryton, MI 49305
Phone
(989) 382-7227
Fax
(989) 382-7227
NPI assigned
Feb 29, 2008
Last updated
Feb 29, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 29, 2008

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

Authorized official

Name
Dr. Kevin T Mathewson, DDS
Title
Dentist Owner
Phone
(989) 382-7227

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

98 Northern Avenue
Barryton, MI 49305

Mailing address

98 Northern Avenue
PO Box 244
Barryton, MI 49305
Phone (989) 382-7227

Other identifiers 1

IdentifierTypeStateIssuer
8012370OtherMIBC BS

Other names 1

  • Jensen Shroyer Anderson PC Former legal business name

National Provider Directory

National Provider Directory
Tax ID family
Jensen Shroyer and Ande3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

NPI Registry JSON

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

{
    "created_epoch": "1204243200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1204243200000",
    "number": "1750550109",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "98 NORTHERN AVENUE",
            "address_2": "PO BOX 244",
            "city": "BARRYTON",
            "state": "MI",
            "postal_code": "49305",
            "telephone_number": "989-382-7227",
            "fax_number": "989-382-7227"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "98 NORTHERN AVENUE",
            "city": "BARRYTON",
            "state": "MI",
            "postal_code": "49305",
            "telephone_number": "989-382-7227",
            "fax_number": "989-382-7227"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ASSOCIATES PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-29",
        "last_updated": "2008-02-29",
        "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": "989-382-7227",
        "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": "BC BS",
            "identifier": "8012370",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jensen Shroyer Anderson PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 29, 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.