Provider Demographics
NPI:1821788936
Name:KATIE KICKERTZ DDS MS PLLC
Entity Type:Organization
Organization Name:KATIE KICKERTZ DDS MS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:KICKERTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:815-222-2102
Mailing Address - Street 1:6842 CARNEGIE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-3500
Mailing Address - Country:US
Mailing Address - Phone:980-423-1272
Mailing Address - Fax:980-423-1273
Practice Address - Street 1:6842 CARNEGIE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3500
Practice Address - Country:US
Practice Address - Phone:980-423-1272
Practice Address - Fax:980-423-1273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty