Healthcare Provider Details

I. General information

NPI: 1720611999
Provider Name (Legal Business Name): AMAIRAINY ACEVEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 N TUSTIN ST
ORANGE CA
92867-7716
US

IV. Provider business mailing address

1210 S LINDA WAY
SANTA ANA CA
92704-3311
US

V. Phone/Fax

Practice location:
  • Phone: 714-288-1035
  • Fax:
Mailing address:
  • Phone: 951-210-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number78734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: