Provider Demographics
NPI:1154161180
Name:SONG, JI SU (DDS)
Entity type:Individual
Prefix:DR
First Name:JI SU
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3416 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-2190
Mailing Address - Country:US
Mailing Address - Phone:612-760-9088
Mailing Address - Fax:
Practice Address - Street 1:2285 NORTHAMPTON ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-3447
Practice Address - Country:US
Practice Address - Phone:413-267-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN10000015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist