Healthcare Provider Details

I. General information

NPI: 1497309306
Provider Name (Legal Business Name): ACEVEDO DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1857 E 4TH ST
ONTARIO CA
91764-2601
US

IV. Provider business mailing address

1857 E 4TH ST
ONTARIO CA
91764-2601
US

V. Phone/Fax

Practice location:
  • Phone: 323-724-1010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MYRA MALTEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 323-724-1010