Provider Demographics
NPI:1346387644
Name:TICOLA, MATTHEW PAUL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PAUL
Last Name:TICOLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11521 US HIGHWAY 431 STE V
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-5671
Mailing Address - Country:US
Mailing Address - Phone:256-505-8954
Mailing Address - Fax:
Practice Address - Street 1:11521 US HIGHWAY 431 STE V
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-5671
Practice Address - Country:US
Practice Address - Phone:256-505-8954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164601223P0221X, 122300000X, 1223P0221X
ALD.00057471223P0221X
ALD00057471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL201595Medicaid