Healthcare Provider Details

I. General information

NPI: 1306159645
Provider Name (Legal Business Name): MATTHEW KIKUCHI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

1459 LANEY WALKER BLVD
AUGUSTA GA
30912-0002
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-9744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7719205-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: