Provider Demographics
NPI:1003973850
Name:ACKERMAN, ROBERT (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E CLEARVUE CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6460
Mailing Address - Country:US
Mailing Address - Phone:208-884-3934
Mailing Address - Fax:
Practice Address - Street 1:10200 W EMERALD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8900
Practice Address - Country:US
Practice Address - Phone:208-376-7954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID30881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID82-0499472OtherTAX ID #
ID3088OtherLICENSE #