Provider Demographics
NPI:1437438769
Name:SONG, EDWARD HANUK (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:HANUK
Last Name:SONG
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 1:10708 PASSERINE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-4215
Mailing Address - Country:US
Mailing Address - Phone:508-333-2269
Mailing Address - Fax:
Practice Address - Street 1:NAVY MEDICINE SUPPORT COMMAND, MEDICAL STAFF SERVICES
Practice Address - Street 2:BLDG. H 2005 KNIGHT LANE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:904-542-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855728122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist