Provider Demographics
NPI:1982626990
Name:BOLDEN, KEVIN TRAMON (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:TRAMON
Last Name:BOLDEN
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 1:3805 DALLAS HWY SW STE 806
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1620
Mailing Address - Country:US
Mailing Address - Phone:678-203-3464
Mailing Address - Fax:678-436-8119
Practice Address - Street 1:780 E WEST CONNECTOR STE 108
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1349
Practice Address - Country:US
Practice Address - Phone:770-702-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX277911223G0001X
GADN0153521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507574Medicaid
TN1513024Medicaid