Provider Demographics
NPI:1720611999
Name:ACEVEDO, AMAIRAINY
Entity Type:Individual
Prefix:
First Name:AMAIRAINY
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 S LINDA WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-3311
Mailing Address - Country:US
Mailing Address - Phone:951-210-8682
Mailing Address - Fax:
Practice Address - Street 1:179 N TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7716
Practice Address - Country:US
Practice Address - Phone:714-288-1035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78734126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA78734Medicaid