Provider Demographics
NPI:1629680053
Name:SON, IN GI (DDS)
Entity Type:Individual
Prefix:
First Name:IN GI
Middle Name:
Last Name:SON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7828 DAY CREEK BLVD APT 727
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8576
Mailing Address - Country:US
Mailing Address - Phone:415-672-3509
Mailing Address - Fax:
Practice Address - Street 1:1136 N MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-2279
Practice Address - Country:US
Practice Address - Phone:415-672-3509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105238122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist