Provider Demographics
NPI:1326127663
Name:ACEVEDO, JASON RANDALL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:RANDALL
Last Name:ACEVEDO
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 1:3461 LAKE TAHOE BLVD
Mailing Address - Street 2:#1
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-544-1050
Mailing Address - Fax:530-544-1709
Practice Address - Street 1:3461 LAKE TAHOE BLVD
Practice Address - Street 2:#1
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-544-1050
Practice Address - Fax:530-544-1709
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA515391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice