Provider Demographics
NPI:1336595651
Name:SONG, JONATHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SONG
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 1:115 W SEMINARY DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2635
Mailing Address - Country:US
Mailing Address - Phone:817-405-0195
Mailing Address - Fax:
Practice Address - Street 1:115 W SEMINARY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-2635
Practice Address - Country:US
Practice Address - Phone:817-405-0195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31771122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist