Provider Demographics
NPI:1336369750
Name:RHIM, SONG B (DMD)
Entity Type:Individual
Prefix:DR
First Name:SONG
Middle Name:B
Last Name:RHIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 PEPPERRELL ST
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5313
Mailing Address - Country:US
Mailing Address - Phone:210-292-2558
Mailing Address - Fax:
Practice Address - Street 1:2133 PEPPERRELL ST
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5313
Practice Address - Country:US
Practice Address - Phone:210-292-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622751223P0300X
MD134731223P0300X
CADDS622751223P0300X
GUD10341223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty