Provider Demographics
NPI:1033255955
Name:SONG, SOOJUNG (DMD)
Entity Type:Individual
Prefix:DR
First Name:SOOJUNG
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24239 HESPERIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-1526
Mailing Address - Country:US
Mailing Address - Phone:510-786-2587
Mailing Address - Fax:
Practice Address - Street 1:3 OCEANSIDE WAY
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94065-1290
Practice Address - Country:US
Practice Address - Phone:617-281-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21420122300000X
CA600611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist