Provider Demographics
NPI:1861019549
Name:SOM, SODARETH JOHN (RDH)
Entity Type:Individual
Prefix:
First Name:SODARETH
Middle Name:JOHN
Last Name:SOM
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 EL CENCERRO
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-3303
Mailing Address - Country:US
Mailing Address - Phone:949-338-6845
Mailing Address - Fax:
Practice Address - Street 1:24012 AVENIDA DE LA CARLOTA
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3100
Practice Address - Country:US
Practice Address - Phone:949-455-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23471124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist