MEDICARE: DR. REGAN WIESEMANN ACKERMAN D.M.D.

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	1223G0001X	General Practice Dentistry	8470	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	208018897	OTHER	KY	TAX ID FOR MORTENSON FAMILY DENTAL (EMPLOYMENT ENDED 1/31/12)
2	454214024	OTHER	KY	BUSINESS TAX ID FOR ACKERMAN FAMILY DENTAL

General Provider Information

NPI Number	:	1871798173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REGAN WIESEMANN ACKERMAN D.M.D.

Provider Business Mailing Address
First Line	:	7600 OUTER LOOP
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40228-1729
Country	:	US
Telephone Number	:	502-231-9970
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 OUTER LOOP
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40228-1729
Country	:	US
Telephone Number	:	502-231-9970
Fax Number	:

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

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	01/29/2012

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