Provider Demographics
NPI:1326305244
Name:SONG, SANDRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-3104
Mailing Address - Country:US
Mailing Address - Phone:516-729-9953
Mailing Address - Fax:
Practice Address - Street 1:323 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4428
Practice Address - Country:US
Practice Address - Phone:630-830-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031350122300000X
PADS039037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist