Healthcare Provider Details

I. General information

NPI: 1386410942
Provider Name (Legal Business Name): WONJO SONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5784 LINDERO CANYON RD STE B
WESTLAKE VILLAGE CA
91362-4088
US

IV. Provider business mailing address

14140 RIVERSIDE DR APT 404
SHERMAN OAKS CA
91423-0018
US

V. Phone/Fax

Practice location:
  • Phone: 818-706-0131
  • Fax:
Mailing address:
  • Phone: 253-335-3248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS112086
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: