Provider Demographics
NPI:1871798173
Name:ACKERMAN, REGAN WIESEMANN (DMD)
Entity type:Individual
Prefix:DR
First Name:REGAN
Middle Name:WIESEMANN
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40228-1729
Mailing Address - Country:US
Mailing Address - Phone:502-231-9970
Mailing Address - Fax:
Practice Address - Street 1:7600 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-1729
Practice Address - Country:US
Practice Address - Phone:502-231-9970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2012-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY84701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY208018897OtherTAX ID FOR MORTENSON FAMILY DENTAL (EMPLOYMENT ENDED 1/31/12)
KY454214024OtherBUSINESS TAX ID FOR ACKERMAN FAMILY DENTAL