Provider Demographics
NPI:1033477229
Name:RIVERA SOTOMAYOR, MARLENE (DMD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:RIVERA SOTOMAYOR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W 190TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-3407
Mailing Address - Country:US
Mailing Address - Phone:212-568-3231
Mailing Address - Fax:
Practice Address - Street 1:520 W 190TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-3407
Practice Address - Country:US
Practice Address - Phone:212-568-3231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056825-1122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice