Provider Demographics
NPI:1386995876
Name:SONG, SEUNGHAN (DMD)
Entity type:Individual
Prefix:DR
First Name:SEUNGHAN
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1201
Mailing Address - Country:US
Mailing Address - Phone:617-424-0606
Mailing Address - Fax:617-424-0006
Practice Address - Street 1:635 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-1201
Practice Address - Country:US
Practice Address - Phone:617-424-0606
Practice Address - Fax:617-424-0006
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18561381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice