Provider Demographics
NPI:1427172204
Name:SONG, YONG CHOL (DDS, FAGD)
Entity type:Individual
Prefix:DR
First Name:YONG
Middle Name:CHOL
Last Name:SONG
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 PARK FOREST SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-2710
Mailing Address - Country:US
Mailing Address - Phone:214-350-8608
Mailing Address - Fax:
Practice Address - Street 1:364 PARK FOREST SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-2710
Practice Address - Country:US
Practice Address - Phone:214-350-8608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16398122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009416101Medicaid