Provider Demographics
NPI:1215596804
Name:SONG, ANDREW WONBIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:WONBIN
Last Name:SONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 MARSHALL CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-2255
Mailing Address - Country:US
Mailing Address - Phone:281-854-4403
Mailing Address - Fax:
Practice Address - Street 1:2713 MARSHALL CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2255
Practice Address - Country:US
Practice Address - Phone:608-442-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002090122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist