Provider Demographics
NPI:1548479777
Name:SONG, MOON J (DDS)
Entity type:Individual
Prefix:
First Name:MOON
Middle Name:J
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 1:2242 CAMDEN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2029
Mailing Address - Country:US
Mailing Address - Phone:408-718-5837
Mailing Address - Fax:408-366-0602
Practice Address - Street 1:2242 CAMDEN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2029
Practice Address - Country:US
Practice Address - Phone:408-718-5837
Practice Address - Fax:408-366-0602
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA420021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice