Basic Information
| Provider Information | |||||||||
| NPI: | 1407297484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TICICH | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4323 HILL STREET | ||||||||
| Address2: | US ARMY DENTAL ACTIVITY | ||||||||
| City: | FORT JACKSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292076022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037516213 | ||||||||
| FaxNumber: | 8037516886 | ||||||||
| Practice Location | |||||||||
| Address1: | 1631 WETZEL AVE BLDG 815 | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 01/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN.00203425 | CO | N | Dental Providers | Dentist | 1223G0001X | 31790 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | 62475 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.