Provider Demographics
NPI:1053590331
Name:KIMATHI, TRAVIS K (DDS)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:K
Last Name:KIMATHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 MONROE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5007
Mailing Address - Country:US
Mailing Address - Phone:404-863-8355
Mailing Address - Fax:
Practice Address - Street 1:375 PARKWAY 575
Practice Address - Street 2:#100
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6439
Practice Address - Country:US
Practice Address - Phone:770-924-0424
Practice Address - Fax:770-592-0636
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.027117122300000X
GADN0137501223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist