Provider Demographics
NPI:1003238650
Name:SONG, ISSE
Entity Type:Individual
Prefix:
First Name:ISSE
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12554 S JOHN YOUNG PKWY
Mailing Address - Street 2:SUITE104
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-4004
Mailing Address - Country:US
Mailing Address - Phone:407-888-1088
Mailing Address - Fax:407-888-1089
Practice Address - Street 1:12554 S JOHN YOUNG PKWY
Practice Address - Street 2:SUITE104
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-4004
Practice Address - Country:US
Practice Address - Phone:407-888-1088
Practice Address - Fax:407-888-1089
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN117031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice