Provider Demographics
NPI:1215127626
Name:GUO, SONG YAN (DDS)
Entity type:Individual
Prefix:DR
First Name:SONG
Middle Name:YAN
Last Name:GUO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:SONG-YAN
Other - Middle Name:
Other - Last Name:GUO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-0949
Mailing Address - Country:US
Mailing Address - Phone:360-426-4712
Mailing Address - Fax:360-426-3220
Practice Address - Street 1:1626 OLYMPIC HWY N
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3060
Practice Address - Country:US
Practice Address - Phone:360-426-4712
Practice Address - Fax:360-426-3220
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010938122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist