Provider Demographics
NPI:1134217870
Name:YOM, JIN SONG (DDS)
Entity type:Individual
Prefix:
First Name:JIN
Middle Name:SONG
Last Name:YOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10973 WATERTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0001
Mailing Address - Country:US
Mailing Address - Phone:619-248-1520
Mailing Address - Fax:
Practice Address - Street 1:8997 MIRA MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2738
Practice Address - Country:US
Practice Address - Phone:858-536-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52791122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist