Provider Demographics
NPI:1114058716
Name:SONG, CLARA H (DDS)
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:H
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11216 NE 15TH STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-454-3221
Mailing Address - Fax:425-454-3213
Practice Address - Street 1:11216 NE 15TH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-454-3221
Practice Address - Fax:425-454-3213
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012271122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA562287022OtherTIN