Provider Demographics
NPI:1093369241
Name:ACKERMAN, DANIEL BRYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRYAN
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10200 W EMERALD ST STE 105
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8900
Mailing Address - Country:US
Mailing Address - Phone:208-376-7954
Mailing Address - Fax:208-323-4859
Practice Address - Street 1:10200 W EMERALD ST STE 105
Practice Address - Street 2:
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:208-323-4859
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5067122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist