Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 019.027117 | IL |
Y | 1223P0221X | Pediatric Dentist | DN013750 | GA |
NPI | 1053590331 |
---|---|
Provider Name | Dr. Travis K Kimathi |
First Address | Atlanta, GA 30324-5007 |
Second Address | Woodstock, GA 30188-6439 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2007 |
Last Update Date | 15/05/2015 |