Provider Demographics
NPI:1073012332
Name:ACEVDO DENTAL GROUP
Entity Type:Organization
Organization Name:ACEVDO DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:
Authorized Official - First Name:LIDYA
Authorized Official - Middle Name:SORAYA
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-724-1010
Mailing Address - Street 1:709 W BEVERLY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-3600
Mailing Address - Country:US
Mailing Address - Phone:323-724-1010
Mailing Address - Fax:323-724-2203
Practice Address - Street 1:709 W BEVERLY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3600
Practice Address - Country:US
Practice Address - Phone:323-724-1010
Practice Address - Fax:323-724-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA554231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty