MEDICARE: DR. JASON RANDALL ACEVEDO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	51539	CA

General Provider Information

NPI Number	:	1326127663
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JASON RANDALL ACEVEDO DDS

Provider Business Mailing Address
First Line	:	3461 LAKE TAHOE BLVD
Second Line	:	#1
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150
Country	:	US
Telephone Number	:	530-544-1050
Fax Number	:	530-544-1709

Provider Business Practice Location Address
First Line	:	3461 LAKE TAHOE BLVD
Second Line	:	#1
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150
Country	:	US
Telephone Number	:	530-544-1050
Fax Number	:	530-544-1709

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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