MEDICARE: TRIPLE EIGHT DENTAL GROUP, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1326659087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIPLE EIGHT DENTAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	7910 W THOMAS RD STE 118
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85033-4830
Country	:	US
Telephone Number	:	623-247-9300
Fax Number	:	623-247-6505

Provider Business Practice Location Address
First Line	:	7910 W THOMAS RD STE 118
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85033-4830
Country	:	US
Telephone Number	:	623-247-9300
Fax Number	:	623-247-6505

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. ROY Y SONG
Credential	:	DMD
Telephone Number	:	623-340-6518

Provider Enumeration Date	:	08/14/2020
Last Update Date	:	08/14/2020

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