1659401750 NPI number — YONG JIN SONG DMD

Table of content: YONG JIN SONG DMD (NPI 1659401750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659401750 NPI number — YONG JIN SONG DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SONG
Provider First Name:
YONG JIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659401750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
527 SE BASELINE ST STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97123-4149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-648-6054
Provider Business Mailing Address Fax Number:
503-648-6099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10009 NE HAZEL DELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-574-3070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  9772 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: D8398 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5050794 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".