Provider Demographics
NPI:1992934418
Name:KICKERTZ, KATIE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:
Last Name:KICKERTZ
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 SHANNON BELL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4425
Mailing Address - Country:US
Mailing Address - Phone:815-222-2102
Mailing Address - Fax:
Practice Address - Street 1:6842 CARNEGIE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3500
Practice Address - Country:US
Practice Address - Phone:980-423-1272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC129491223E0200X
SC106081223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics