Provider Demographics
NPI:1457974214
Name:SON, KEVIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:SON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 MEADOW ROSE
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-5963
Mailing Address - Country:US
Mailing Address - Phone:240-422-3724
Mailing Address - Fax:
Practice Address - Street 1:1110 TOWN CENTER BLVD STE H
Practice Address - Street 2:
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1232
Practice Address - Country:US
Practice Address - Phone:410-874-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD175191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program