Provider Demographics
NPI:1396422796
Name:SONG, GRACE (DDS)
Entity type:Individual
Prefix:DR
First Name:GRACE
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 1:3918 S KENYON ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-4065
Mailing Address - Country:US
Mailing Address - Phone:240-401-8383
Mailing Address - Fax:
Practice Address - Street 1:3708 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4419
Practice Address - Country:US
Practice Address - Phone:253-215-1107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE614341791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice