Provider Demographics
NPI:1225178403
Name:SONG, KI Y (DDS)
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:Y
Last Name:SONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 CAJON ST #3
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5239
Mailing Address - Country:US
Mailing Address - Phone:909-793-5684
Mailing Address - Fax:
Practice Address - Street 1:233 CAJON ST #3
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5239
Practice Address - Country:US
Practice Address - Phone:909-793-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist