MEDICARE: MARLENE RIVERA SOTOMAYOR DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	056825-1	NY
2	1223G0001X	General Practice Dentistry	056825-1	NY

General Provider Information

NPI Number	:	1033477229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLENE RIVERA SOTOMAYOR DMD

Provider Business Mailing Address
First Line	:	520 W 190TH ST
Second Line	:	SUITE A
City	:	NEW YORK
State	:	NY
Zip	:	10040-3407
Country	:	US
Telephone Number	:	212-568-3231
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 W 190TH ST
Second Line	:	SUITE A
City	:	NEW YORK
State	:	NY
Zip	:	10040-3407
Country	:	US
Telephone Number	:	212-568-3231
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2012
Last Update Date	:	08/21/2013

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