Provider Demographics
NPI:1699880500
Name:SONG, KEVIN K (DMD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
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 1:595 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-1911
Mailing Address - Country:US
Mailing Address - Phone:617-769-0888
Mailing Address - Fax:617-479-9888
Practice Address - Street 1:595 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02170-1911
Practice Address - Country:US
Practice Address - Phone:617-769-0888
Practice Address - Fax:617-479-9888
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA188581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice