Provider Demographics
NPI:1598816324
Name:SONG, SOO YOUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:SOO YOUNG
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 1:25064 PROSPECT AVE # A
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2960
Mailing Address - Country:US
Mailing Address - Phone:909-913-8887
Mailing Address - Fax:909-478-1061
Practice Address - Street 1:25064 PROSPECT AVE # A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2960
Practice Address - Country:US
Practice Address - Phone:909-913-8887
Practice Address - Fax:909-478-1061
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist