Healthcare Provider Details

I. General information

NPI: 1457974214
Provider Name (Legal Business Name): KEVIN SON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 08/08/2021
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 TOWN CENTER BLVD STE H
ODENTON MD
21113-1232
US

IV. Provider business mailing address

5931 MEADOW ROSE
ELKRIDGE MD
21075-5963
US

V. Phone/Fax

Practice location:
  • Phone: 410-874-2222
  • Fax:
Mailing address:
  • Phone: 240-422-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number17519
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: