Healthcare Provider Details

I. General information

NPI: 1164599569
Provider Name (Legal Business Name): LIANSHENG SONG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 03/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE DIVISION OF OMS L-7073, MC1720
FARMINGTON CT
06030-1720
US

IV. Provider business mailing address

263 FARMINGTON AVE DIVISION OF OMS L-7073, MC1720
FARMINGTON CT
06030-1720
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2583
  • Fax: 860-679-1702
Mailing address:
  • Phone: 860-679-2583
  • Fax: 860-679-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number010234
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number010234
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: