Provider Demographics
NPI:1235318569
Name:SONG, MICHAEL SOO-HYUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SOO-HYUNG
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 1:3975 FAIR RIDGE DR
Mailing Address - Street 2:SUITE #301 NORTH
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2911
Mailing Address - Country:US
Mailing Address - Phone:703-385-5455
Mailing Address - Fax:
Practice Address - Street 1:3975 FAIR RIDGE DR
Practice Address - Street 2:SUITE #301 NORTH
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2911
Practice Address - Country:US
Practice Address - Phone:703-385-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist