Provider Demographics
NPI:1841711272
Name:KICKLIGHTER, ANDREW (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
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 1:2122 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:GA
Mailing Address - Zip Code:31790-2814
Mailing Address - Country:US
Mailing Address - Phone:229-567-4295
Mailing Address - Fax:
Practice Address - Street 1:3208 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-3721
Practice Address - Country:US
Practice Address - Phone:478-953-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist