Provider Demographics
NPI:1982188934
Name:SONG DENTAL CORPORATION
Entity Type:Organization
Organization Name:SONG DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-719-6842
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 1:2920 HUNTINGTON DR STE 238
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108-2254
Practice Address - Country:US
Practice Address - Phone:626-286-9211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-16
Last Update Date:2018-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental