Provider Demographics
NPI:1639349970
Name:MATHEWS, KIM JACKSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:JACKSON
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 NEWNAN CROSSING BLVD E
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2408
Mailing Address - Country:US
Mailing Address - Phone:770-251-5777
Mailing Address - Fax:
Practice Address - Street 1:2401 NEWNAN CROSSING BLVD E
Practice Address - Street 2:SUITE 210
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2408
Practice Address - Country:US
Practice Address - Phone:770-251-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA121981223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry