Provider Demographics
NPI:1699376442
Name:SOTO, KATHLEEN CAROL
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CAROL
Last Name:SOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18645 HATTERAS ST UNIT 269
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1875
Mailing Address - Country:US
Mailing Address - Phone:805-300-8773
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD STE 912
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3906
Practice Address - Country:US
Practice Address - Phone:805-300-8773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-06
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24289124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist