Provider Demographics
NPI:1407297484
Name:TICICH, MATTHEW E (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:E
Last Name:TICICH
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 1:4323 HILL STREET
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY
Mailing Address - City:FORT JACKSON
Mailing Address - State:SC
Mailing Address - Zip Code:29207-6022
Mailing Address - Country:US
Mailing Address - Phone:803-751-6213
Mailing Address - Fax:803-751-6886
Practice Address - Street 1:6145 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5558
Practice Address - Country:US
Practice Address - Phone:951-529-2070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00203425122300000X
TX317901223G0001X
CA624751223G0001X
TN118691223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice