Provider Demographics
NPI:1558453431
Name:SONG, JIN WOOK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:WOOK
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-0716
Mailing Address - Country:US
Mailing Address - Phone:315-493-6003
Mailing Address - Fax:315-376-3268
Practice Address - Street 1:35761 SAYRE RD
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-8522
Practice Address - Country:US
Practice Address - Phone:315-493-6003
Practice Address - Fax:315-493-6828
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048707-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist