Provider Demographics
NPI:1194813030
Name:KIRKLEY, MATTHEW SCOTT (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:KIRKLEY
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 1:2803 WRIGHTSBORO RD
Mailing Address - Street 2:SUITE 25
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3913
Mailing Address - Country:US
Mailing Address - Phone:706-733-0223
Mailing Address - Fax:706-733-2370
Practice Address - Street 1:2803 WRIGHTSBORO RD
Practice Address - Street 2:SUITE 25
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-3913
Practice Address - Country:US
Practice Address - Phone:706-733-0223
Practice Address - Fax:706-733-2370
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0125381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZG2538Medicaid