Provider Demographics
NPI:1881873552
Name:ACEVEDO, LIDYA SORAYA
Entity type:Individual
Prefix:
First Name:LIDYA
Middle Name:SORAYA
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 1:257 S REEVES DR
Mailing Address - Street 2:PH
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4046
Mailing Address - Country:US
Mailing Address - Phone:786-290-3652
Mailing Address - Fax:
Practice Address - Street 1:11976 AVIATION BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-1001
Practice Address - Country:US
Practice Address - Phone:310-643-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA554231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice