Provider Demographics
NPI:1790201762
Name:ACEVEDO DENTAL OFFICE, INC.
Entity type:Organization
Organization Name:ACEVEDO DENTAL OFFICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LIDYA
Authorized Official - Middle Name:SORAYA
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-724-1010
Mailing Address - Street 1:2800 N MAIN ST UNIT 1010
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-6608
Mailing Address - Country:US
Mailing Address - Phone:714-617-7979
Mailing Address - Fax:714-617-7278
Practice Address - Street 1:2800 N MAIN ST UNIT 1010
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6608
Practice Address - Country:US
Practice Address - Phone:714-617-7979
Practice Address - Fax:714-617-7278
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACEVEDO DENTAL OFFICE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA554231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty