Provider Demographics
NPI:1497248017
Name:JINJU SONG DMD PLLC
Entity Type:Organization
Organization Name:JINJU SONG DMD PLLC
Other - Org Name:JUANITA KIDS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JINJU
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:425-310-8338
Mailing Address - Street 1:9707 NE 119TH WAY
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-8955
Mailing Address - Country:US
Mailing Address - Phone:425-310-8338
Mailing Address - Fax:425-449-5933
Practice Address - Street 1:9707 NE 119TH WAY
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-8955
Practice Address - Country:US
Practice Address - Phone:425-310-8338
Practice Address - Fax:425-449-5933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE603005171223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1255644316OtherINDIVIDUAL NPI
WADE60300517OtherLICENSE