NPIMap

Organization Active NPI

Professional Dental Associates PC

  • General Practice Dentistry
  • Big Rapids, MI
National Provider Identifier
1992863401
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
2901016945 Issued in MI
Legal business name
PROFESSIONAL DENTAL ASSOCIATES PC
Practice address
415 South State Street
Big Rapids, MI 49307-2049
Phone
(231) 796-3571
Fax
(231) 796-2211
NPI assigned
Dec 5, 2006
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Dr. Kevin Todd 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 connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice Dentistry 1223G0001X 2901019404 MI
General Practice Dentistry 1223G0001X 2901010102 MI
General Practice Dentistry 1223G0001X 2901019403 MI
General Practice Dentistry 1223G0001X 2901016945 MI Primary

Addresses

Primary practice location

415 South State Street
Big Rapids, MI 49307-2049

Mailing address

415 South State Street
Big Rapids, MI 49307-2049
Phone (231) 796-3571

Other identifiers 4

IdentifierTypeStateIssuer
D8012370OtherMIBCBS
1883236OtherMIUNITED CONCORDIA
D802980OtherMIBCBS
D8012380OtherMIBCBS

Other names 1

  • Jensen Shroyer 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

Other organizations with this tax ID 2

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

Locations

415 S State St
Big Rapids, MI 49307
Phone (231) 296-3571

Practitioners & affiliated clinicians

Practitioners 6

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": "1165276800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1992863401",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "415 SOUTH STATE STREET",
            "city": "BIG RAPIDS",
            "state": "MI",
            "postal_code": "493072049",
            "telephone_number": "231-796-3571",
            "fax_number": "231-796-2211"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "415 SOUTH STATE STREET",
            "city": "BIG RAPIDS",
            "state": "MI",
            "postal_code": "493072049",
            "telephone_number": "231-796-3571",
            "fax_number": "231-796-2211"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ASSOCIATES PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-12-05",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MATHEWSON",
        "authorized_official_first_name": "KEVIN",
        "authorized_official_middle_name": "TODD",
        "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": "2901019404",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901010102",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901019403",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MI",
            "license": "2901016945",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "D8012370",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED CONCORDIA",
            "identifier": "1883236",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "D802980",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "D8012380",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Jensen Shroyer Anderson PC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Big Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.