Provider Demographics
NPI:1154932218
Name:SONG, MYOUNGSU
Entity type:Individual
Prefix:
First Name:MYOUNGSU
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 E ALGONQUIN RD STE 610
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:
Practice Address - Street 1:819 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-2101
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190327941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice