Provider Demographics
NPI:1659718484
Name:ACEVEDO, NELLIE M (RDA)
Entity Type:Individual
Prefix:MS
First Name:NELLIE
Middle Name:M
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 E TUCKER ST
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1282
Mailing Address - Country:US
Mailing Address - Phone:323-246-3894
Mailing Address - Fax:
Practice Address - Street 1:9910 LONG BEACH BLVD STE A
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-1561
Practice Address - Country:US
Practice Address - Phone:323-563-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56812126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant