Provider Demographics
NPI:1386483063
Name:SOTILLO, AMANDA (MS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SOTILLO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 EDENWOOD DR APT 208
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6977
Mailing Address - Country:US
Mailing Address - Phone:312-813-9344
Mailing Address - Fax:
Practice Address - Street 1:1011 N UNIVERSITY AVE RM 3376
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1078
Practice Address - Country:US
Practice Address - Phone:734-763-3326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-22
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29510009511223P0700X
MI29016022901223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics