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 1:7500 GREEN BAY RD STE 200
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4045
Mailing Address - Country:US
Mailing Address - Phone:262-842-7022
Mailing Address - Fax:
Practice Address - Street 1:7500 GREEN BAY RD STE 200
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4045
Practice Address - Country:US
Practice Address - Phone:262-842-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002174-151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics