Provider Demographics
NPI:1790067460
Name:SONG, BENJAMIN W (DMD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:W
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 1:2053 PALM VISTA DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2454
Mailing Address - Country:US
Mailing Address - Phone:386-235-6683
Mailing Address - Fax:
Practice Address - Street 1:2053 PALM VISTA DRIVE
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712
Practice Address - Country:US
Practice Address - Phone:386-235-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 217941223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program