Provider Demographics
NPI:1639415987
Name:YANG, SONG (DMD)
Entity Type:Individual
Prefix:DR
First Name:SONG
Middle Name:
Last Name:YANG
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 1:3620 HUFFINES BLVD APT # 3013
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010
Mailing Address - Country:US
Mailing Address - Phone:646-884-0518
Mailing Address - Fax:
Practice Address - Street 1:3620 HUFFINES BLVD APT # 3013
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010
Practice Address - Country:US
Practice Address - Phone:646-884-0518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18561411223G0001X
TX286031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice