Provider Demographics
NPI:1467571554
Name:SONG, IMMI (DDS, MS)
Entity Type:Individual
Prefix:MS
First Name:IMMI
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SOLANO AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1825
Mailing Address - Country:US
Mailing Address - Phone:510-528-2220
Mailing Address - Fax:510-528-2280
Practice Address - Street 1:1301 SOLANO AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-1825
Practice Address - Country:US
Practice Address - Phone:510-528-2220
Practice Address - Fax:510-528-2280
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics