Provider Demographics
NPI:1326158114
Name:ACKER, PHILIP MATTHEW (DDS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:MATTHEW
Last Name:ACKER
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 1:502 W WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:MILLSTADT
Mailing Address - State:IL
Mailing Address - Zip Code:62260
Mailing Address - Country:US
Mailing Address - Phone:618-476-7045
Mailing Address - Fax:618-476-7278
Practice Address - Street 1:502 W WASHINGTON
Practice Address - Street 2:
Practice Address - City:MILLSTADT
Practice Address - State:IL
Practice Address - Zip Code:62260
Practice Address - Country:US
Practice Address - Phone:618-476-7045
Practice Address - Fax:618-476-7278
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-024379122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist