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General NPI Number Information
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NPI Number | 1750550109
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL DENTAL ASSOCIATES PC
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Dates
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Enumeration Date | 02/29/2008
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Last Update Date | 02/29/2008
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Provider Practice Location Address
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Address Line | 98 NORTHERN AVENUE
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City | BARRYTON
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State | MI
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Zip | 49305
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Country | US
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Telephone | 989-382-7227
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Fax | 989-382-7227
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Provider Business Mailing Address
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Address Line | 98 NORTHERN AVENUE PO BOX 244
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City | BARRYTON
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State | MI
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Zip | 49305
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Country | US
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Telephone | 989-382-7227
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Fax | 989-382-7227
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Authorized Official
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Title or Position | DENTIST OWNER
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Name | DR. KEVIN T MATHEWSON
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Credential | DDS
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Telephone | 989-382-7227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16945
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 19296
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 10102
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License Number State | MI
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