Provider Demographics
NPI:1184185753
Name:ELIZABETH SOTOMIL DDS, INC
Entity Type:Organization
Organization Name:ELIZABETH SOTOMIL DDS, INC
Other - Org Name:SMILE HARVEST DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:MANZO
Authorized Official - Last Name:SOTOMIL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-526-1190
Mailing Address - Street 1:3609 COFFEE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1100
Mailing Address - Country:US
Mailing Address - Phone:209-526-1190
Mailing Address - Fax:209-526-3245
Practice Address - Street 1:3609 COFFEE RD STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1100
Practice Address - Country:US
Practice Address - Phone:209-526-1190
Practice Address - Fax:209-526-3245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1154629566Medicaid