MEDICARE: DR. EDWARD HANUK SONG D.M.D.

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	1223E0200X	Endodontics	1002174-15	WI

General Provider Information

NPI Number	:	1437438769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD HANUK SONG D.M.D.

Provider Business Mailing Address
First Line	:	7500 GREEN BAY RD STE 200
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-4045
Country	:	US
Telephone Number	:	262-842-7022
Fax Number	:

Provider Business Practice Location Address
First Line	:	7500 GREEN BAY RD STE 200
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-4045
Country	:	US
Telephone Number	:	262-842-7022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2011
Last Update Date	:	10/07/2025

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