Provider Demographics
NPI:1346591906
Name:SONG, TAE GON (DDS)
Entity Type:Individual
Prefix:
First Name:TAE
Middle Name:GON
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 1:507 N GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3405
Mailing Address - Country:US
Mailing Address - Phone:972-329-7000
Mailing Address - Fax:
Practice Address - Street 1:507 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3405
Practice Address - Country:US
Practice Address - Phone:972-329-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX282951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice