Provider Demographics
NPI:1659319655
Name:DR. ISSE SONG DENTAL OFFICE
Entity Type:Organization
Organization Name:DR. ISSE SONG DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.M.D., PH. D.,FAGD/ DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:407-888-1088
Mailing Address - Street 1:12554 S JOHN YOUNG PKWY
Mailing Address - Street 2:#104
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-4004
Mailing Address - Country:US
Mailing Address - Phone:407-888-1088
Mailing Address - Fax:407-888-1889
Practice Address - Street 1:12554 S JOHN YOUNG PKWY
Practice Address - Street 2:#104
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-4004
Practice Address - Country:US
Practice Address - Phone:407-888-1088
Practice Address - Fax:407-888-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN117031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty