Basic Information
Provider Information | |||||||||
NPI: | 1144338856 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOTTO | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 110 S WOODLAND ST | ||||||||
Address2: |   | ||||||||
City: | WINTER GARDEN | ||||||||
State: | FL | ||||||||
PostalCode: | 347873546 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4079058827 | ||||||||
FaxNumber: | 4079058980 | ||||||||
Practice Location | |||||||||
Address1: | 1210 E PLANT ST | ||||||||
Address2: |   | ||||||||
City: | WINTER GARDEN | ||||||||
State: | FL | ||||||||
PostalCode: | 347872996 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078774310 | ||||||||
FaxNumber: | 4076544582 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2006 | ||||||||
LastUpdateDate: | 06/10/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DN 17525 | FL | Y |   | Dental Providers | Dentist | General Practice | 1223P0221X | DN17525 | FL | N |   | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
ID | Type | State | Issuer | Description | BS 9863312 | 01 | FL | DEA | OTHER | 000339200 | 05 | FL |   | MEDICAID |