Provider Demographics
NPI:1720204126
Name:ACKERMANN, CHRISTINE LAURA (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:LAURA
Last Name:ACKERMANN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 BRIDLE CREEK ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4932
Mailing Address - Country:US
Mailing Address - Phone:616-281-9757
Mailing Address - Fax:
Practice Address - Street 1:12715 W M-179 HWY
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348
Practice Address - Country:US
Practice Address - Phone:269-795-7861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010160811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice