Provider Demographics
NPI:1215190947
Name:SONG, SOO OK
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:OK
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:344 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BARNSTABLE
Mailing Address - State:MA
Mailing Address - Zip Code:02601
Mailing Address - Country:US
Mailing Address - Phone:508-771-7751
Mailing Address - Fax:508-771-7753
Practice Address - Street 1:344 MAIN ST
Practice Address - Street 2:
Practice Address - City:BARNSTABLE
Practice Address - State:MA
Practice Address - Zip Code:02601
Practice Address - Country:US
Practice Address - Phone:508-771-7751
Practice Address - Fax:508-771-7753
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0206822Medicaid