Provider Demographics
NPI:1841741360
Name:SONG, ESTHER
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ESTHER
Other - Middle Name:
Other - Last Name:KWEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2672 S CARL PL
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-4182
Mailing Address - Country:US
Mailing Address - Phone:909-361-0106
Mailing Address - Fax:
Practice Address - Street 1:2672 S CARL PL
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-4182
Practice Address - Country:US
Practice Address - Phone:909-361-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1008051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice