Provider Demographics
NPI:1225486947
Name:PARK, SONG YONG (DMD)
Entity Type:Individual
Prefix:DR
First Name:SONG
Middle Name:YONG
Last Name:PARK
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 1:412 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:HOGANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13655-3109
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-2797
Practice Address - Street 1:412 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655-3109
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-2797
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059200122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04880291Medicaid