Basic Information
| Provider Information | |||||||||
| NPI: | 1982626990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLDEN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | TRAMON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 DALLAS HWY SW STE 806 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300641620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782033464 | ||||||||
| FaxNumber: | 6784368119 | ||||||||
| Practice Location | |||||||||
| Address1: | 780 E WEST CONNECTOR STE 108 | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707027850 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 27791 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | DN015352 | GA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1507574 | 05 | TN | MEDICAID | 1513024 | 05 | TN | MEDICAID |