MEDICARE: DR. ABIGAIL ANN DIERKING DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	2901019890	MI
2	122300000X	Dentist	12011203A	IN
3	122300000X	Dentist	10375	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5315037627	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1508015520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ABIGAIL ANN DIERKING DDS

Provider Business Mailing Address
First Line	:	7231 MEADOW RIDGE DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-3780
Country	:	US
Telephone Number	:	317-361-6493
Fax Number	:

Provider Business Practice Location Address
First Line	:	3002 BARDSTOWN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-3020
Country	:	US
Telephone Number	:	502-451-2212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2008
Last Update Date	:	03/24/2020

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