Provider Demographics
NPI:1619969516
Name:ACEVEDO, JOAN (D)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 BOGGY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4428
Mailing Address - Country:US
Mailing Address - Phone:407-343-2000
Mailing Address - Fax:407-343-2002
Practice Address - Street 1:105 N DOVERPLUM AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34758-3309
Practice Address - Country:US
Practice Address - Phone:407-943-8600
Practice Address - Fax:407-943-8625
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2012-12-17
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
PR20151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000898200Medicaid
PR206202OtherUTI
PR41822OtherTSSS REFORMA
PR9600072OtherHUMANA
PR041584OtherBLUE CROSS
80260OtherACMS
PR2678OtherIMC
PR740270OtherUNITED CONCORDIA