MEDICARE: DR. BEVERLY SHARON SOTTO FONTEJON DDS

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	1223G0001X	General Practice Dentistry	53651	CA

General Provider Information

NPI Number	:	1255482170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BEVERLY SHARON SOTTO FONTEJON DDS

Provider Business Mailing Address
First Line	:	19123 AMBER VALLEY DR
Second Line	:
City	:	WALNUT
State	:	CA
Zip	:	91789-4180
Country	:	US
Telephone Number	:	626-893-3589
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 W SAN BERNARDINO RD
Second Line	:
City	:	COVINA
State	:	CA
Zip	:	91723-1516
Country	:	US
Telephone Number	:	626-339-1180
Fax Number	:	626-339-2280

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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