Provider Demographics
NPI:1417689761
Name:SONG, SUN YOUNG
Entity Type:Individual
Prefix:DR
First Name:SUN YOUNG
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUN YOUG
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3909 GALLANT FOX DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-4831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS OSBOURNE, BUILDING 1017
Practice Address - Street 2:NMRTC GREAT LAKES
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:847-688-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022021331122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist