Provider Demographics
NPI:1154629566
Name:SOTOMIL, ELIZABETH MANZO
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MANZO
Last Name:SOTOMIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NA
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:3400 COFFEE RD APT 346
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1580
Mailing Address - Country:US
Mailing Address - Phone:323-889-9303
Mailing Address - Fax:
Practice Address - Street 1:3400 COFFEE RD APT 346
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1580
Practice Address - Country:US
Practice Address - Phone:323-889-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60119122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice