Healthcare Provider Details

I. General information

NPI: 1356756423
Provider Name (Legal Business Name): LONG RIDGE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 MAIN ST
BRIDGEPORT CT
06606-3609
US

IV. Provider business mailing address

3741 MAIN ST
BRIDGEPORT CT
06606-3609
US

V. Phone/Fax

Practice location:
  • Phone: 475-282-4912
  • Fax: 475-282-4915
Mailing address:
  • Phone: 475-282-4912
  • Fax: 475-282-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. KIGON SONG
Title or Position: OWNER
Credential: DDS
Phone: 646-369-6918