MEDICARE: ACEVEDO DENTAL CORP

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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1497309306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACEVEDO DENTAL CORP

Provider Business Mailing Address
First Line	:	1857 E 4TH ST
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91764-2601
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1857 E 4TH ST
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91764-2601
Country	:	US
Telephone Number	:	323-724-1010
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MYRA MALTEZ
Credential	:
Telephone Number	:	323-724-1010

Provider Enumeration Date	:	07/29/2019
Last Update Date	:	07/29/2019

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Directions to “ACEVEDO DENTAL CORP ” Practice Location

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