Provider Demographics
NPI:1891862850
Name:ACKERMAN, STACY ANN (DDS, MMSC)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANN
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:DDS, MMSC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 2949
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:CO
Mailing Address - Zip Code:80435-2949
Mailing Address - Country:US
Mailing Address - Phone:970-262-7664
Mailing Address - Fax:970-262-7604
Practice Address - Street 1:325 LAKE DILLON DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:DILLON
Practice Address - State:CO
Practice Address - Zip Code:80435-2949
Practice Address - Country:US
Practice Address - Phone:970-262-7664
Practice Address - Fax:970-262-7604
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8624122300000X
MA21556122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist