Provider Demographics
NPI:1750740072
Name:SONG, SOO KYUNG (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:SOO
Middle Name:KYUNG
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:SOO
Other - Middle Name:KYUNG
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:100 E VALENCIA MESA DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3816
Mailing Address - Country:US
Mailing Address - Phone:714-992-5437
Mailing Address - Fax:
Practice Address - Street 1:100 E VALENCIA MESA DR STE 102
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3816
Practice Address - Country:US
Practice Address - Phone:714-992-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA1011421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program