Provider Demographics
NPI:1609904374
Name:ACEVEDO, AMOS BENJAMIN (DDS)
Entity Type:Individual
Prefix:MR
First Name:AMOS
Middle Name:BENJAMIN
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 1:774 CUESTA ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1783
Mailing Address - Country:US
Mailing Address - Phone:805-704-3591
Mailing Address - Fax:
Practice Address - Street 1:21890 COLORADO AVE.
Practice Address - Street 2:
Practice Address - City:SAN JOAQUIN
Practice Address - State:CA
Practice Address - Zip Code:93660
Practice Address - Country:US
Practice Address - Phone:559-693-2467
Practice Address - Fax:559-693-2398
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03875FMedicaid