Provider Demographics
NPI:1265173066
Name:SONG, JESSICA YOONA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:YOONA
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 SOUTH RD STE 16
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-7211
Mailing Address - Country:US
Mailing Address - Phone:845-462-2000
Mailing Address - Fax:
Practice Address - Street 1:2020 SOUTH RD STE 16
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-7211
Practice Address - Country:US
Practice Address - Phone:845-462-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063458122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist