1992863401 NPI number — PROFESSIONAL DENTAL ASSOCIATES PC

Table of content: (NPI 1992863401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992863401 NPI number — PROFESSIONAL DENTAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL DENTAL ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JENSEN SHROYER ANDERSON PC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992863401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 SOUTH STATE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIG RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49307-2049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-796-3571
Provider Business Mailing Address Fax Number:
231-796-2211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 SOUTH STATE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIG RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49307-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-796-3571
Provider Business Practice Location Address Fax Number:
231-796-2211
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2901019404 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2901010102 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 2901016945 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 2901019403 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D8012370 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1883236 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: D802980 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: D8012380 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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