Healthcare Provider Details

I. General information

NPI: 1407297484
Provider Name (Legal Business Name): MATTHEW TICICH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6145 DESERT STORM AVE
FORT CAMPBELL KY
42223-5558
US

IV. Provider business mailing address

40203 ODESSA DR
TEMECULA CA
92591-6167
US

V. Phone/Fax

Practice location:
  • Phone: 951-529-2070
  • Fax:
Mailing address:
  • Phone: 951-529-2070
  • Fax: 803-751-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number11869
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number112743
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN.00203425
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number31790
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: