Provider Demographics
NPI:1417075623
Name:KICKLIGHTER, LES J (DMD)
Entity Type:Individual
Prefix:DR
First Name:LES
Middle Name:J
Last Name:KICKLIGHTER
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 1:100 NOTTINGHAM TRL
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4265
Mailing Address - Country:US
Mailing Address - Phone:912-489-2565
Mailing Address - Fax:
Practice Address - Street 1:512 GENTILLY RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5149
Practice Address - Country:US
Practice Address - Phone:912-489-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0124011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00956007AMedicaid