Provider Demographics
NPI:1821343518
Name:KICKLITER, MATTHEW BLAKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BLAKE
Last Name:KICKLITER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:KICKLITER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1950 W MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3764
Mailing Address - Country:US
Mailing Address - Phone:423-586-8144
Mailing Address - Fax:
Practice Address - Street 1:1950 W MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3764
Practice Address - Country:US
Practice Address - Phone:423-586-8144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice