Healthcare Provider Details

I. General information

NPI: 1619314556
Provider Name (Legal Business Name): GEORGE YI-JAAN SOUNG DDS, FAAOMS, FACOMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2013
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14746 LANCASTER HWY # B
PINEVILLE NC
28134-9313
US

IV. Provider business mailing address

3731 PARK SOUTH STATION BLVD
CHARLOTTE NC
28210-4473
US

V. Phone/Fax

Practice location:
  • Phone: 704-583-5217
  • Fax: 704-200-9913
Mailing address:
  • Phone: 724-244-2628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9533
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: