Healthcare Provider Details

I. General information

NPI: 1609904374
Provider Name (Legal Business Name): AMOS BENJAMIN ACEVEDO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21890 COLORADO AVE.
SAN JOAQUIN CA
93660
US

IV. Provider business mailing address

774 CUESTA ST
MORRO BAY CA
93442-1783
US

V. Phone/Fax

Practice location:
  • Phone: 559-693-2467
  • Fax: 559-693-2398
Mailing address:
  • Phone: 805-704-3591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number27943
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: