Healthcare Provider Details

I. General information

NPI: 1922084276
Provider Name (Legal Business Name): JACK T ACKERMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19059 VALLEY BLVD SUITE 103
BLOOMINGTON CA
92316-2219
US

IV. Provider business mailing address

19059 VALLEY BLVD SUITE 103
BLOOMINGTON CA
92316-2219
US

V. Phone/Fax

Practice location:
  • Phone: 909-877-3660
  • Fax: 909-877-3682
Mailing address:
  • Phone: 909-877-3660
  • Fax: 909-877-3682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: