Provider Demographics
NPI:1679833990
Name:KIMATHI PEDIATRIC DENTISTRY PC
Entity Type:Organization
Organization Name:KIMATHI PEDIATRIC DENTISTRY PC
Other - Org Name:FIRST CARE PEDIATRIC DENTISTRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMATHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-942-1260
Mailing Address - Street 1:3432 HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2310
Mailing Address - Country:US
Mailing Address - Phone:770-942-1260
Mailing Address - Fax:770-942-9244
Practice Address - Street 1:3432 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2310
Practice Address - Country:US
Practice Address - Phone:770-942-1260
Practice Address - Fax:770-942-9244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0137501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty