Provider Demographics
NPI:1023456753
Name:SONG, JIN (DDS)
Entity type:Individual
Prefix:DR
First Name:JIN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JIN
Other - Middle Name:HA
Other - Last Name:SUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2611 S QUILLAN PL STE 110
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-1899
Mailing Address - Country:US
Mailing Address - Phone:509-585-5437
Mailing Address - Fax:
Practice Address - Street 1:2611 S QUILLAN PL STE 110
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-1899
Practice Address - Country:US
Practice Address - Phone:509-585-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29005122300000X
WADE615169401223D0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health