Provider Demographics
NPI:1811399306
Name:ACEVEDO, ROSEMARIE (DDS)
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6725 DE CELIS PL
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-5713
Mailing Address - Country:US
Mailing Address - Phone:818-781-6030
Mailing Address - Fax:
Practice Address - Street 1:11559 SHERMAN WAY UNIT 100
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-5883
Practice Address - Country:US
Practice Address - Phone:818-503-0040
Practice Address - Fax:818-503-0090
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA435071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice