Provider Demographics
NPI:1740511310
Name:SONG, SEJIN SHANE (DDS)
Entity type:Individual
Prefix:DR
First Name:SEJIN
Middle Name:SHANE
Last Name:SONG
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 1:107 WASHBURNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PAYNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56362
Mailing Address - Country:US
Mailing Address - Phone:320-243-2175
Mailing Address - Fax:320-243-8158
Practice Address - Street 1:107 WASHBURNE AVE
Practice Address - Street 2:
Practice Address - City:PAYNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56362-1640
Practice Address - Country:US
Practice Address - Phone:320-243-2175
Practice Address - Fax:320-243-8158
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND131821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice