Provider Demographics
NPI:1659401750
Name:SONG, YONG JIN (DMD)
Entity Type:Individual
Prefix:
First Name:YONG JIN
Middle Name:
Last Name:SONG
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 1:527 SE BASELINE ST STE C
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4149
Mailing Address - Country:US
Mailing Address - Phone:503-648-6054
Mailing Address - Fax:503-648-6099
Practice Address - Street 1:10009 NE HAZEL DELL AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685
Practice Address - Country:US
Practice Address - Phone:360-574-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA9772122300000X
ORD83981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5050794Medicaid