Provider Demographics
NPI:1659160604
Name:SONG, ANGELICA (DMD)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5712 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1318
Mailing Address - Country:US
Mailing Address - Phone:314-742-8038
Mailing Address - Fax:
Practice Address - Street 1:4171 CRESCENT DR STE 102
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3645
Practice Address - Country:US
Practice Address - Phone:314-742-8038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025021915202C00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program