Provider Demographics
NPI:1659757375
Name:SONG, JONATHAN (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SONG
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 1:936 S OLIVE ST APT 734
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3679
Mailing Address - Country:US
Mailing Address - Phone:262-719-6842
Mailing Address - Fax:
Practice Address - Street 1:1134 N STATE COLLEGE BLVD STE C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806
Practice Address - Country:US
Practice Address - Phone:714-772-2698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA648491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice