MEDICARE: JACK T ACKERMAN 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	1223G0001X	General Practice Dentistry	35370	CA

General Provider Information

NPI Number	:	1922084276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK T ACKERMAN DDS

Provider Business Mailing Address
First Line	:	19059 VALLEY BLVD
Second Line	:	SUITE 103
City	:	BLOOMINGTON
State	:	CA
Zip	:	92316-2219
Country	:	US
Telephone Number	:	909-877-3660
Fax Number	:	909-877-3682

Provider Business Practice Location Address
First Line	:	19059 VALLEY BLVD
Second Line	:	SUITE 103
City	:	BLOOMINGTON
State	:	CA
Zip	:	92316-2219
Country	:	US
Telephone Number	:	909-877-3660
Fax Number	:	909-877-3682

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

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	08/06/2007

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