Healthcare Provider Details

I. General information

NPI: 1033571203
Provider Name (Legal Business Name): DISCOUNT DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14210 ROOSEVELT AVE # 8
FLUSHING NY
11354-6046
US

IV. Provider business mailing address

14210 ROOSEVELT AVE # 8
FLUSHING NY
11354-6046
US

V. Phone/Fax

Practice location:
  • Phone: 718-460-6868
  • Fax: 718-460-2112
Mailing address:
  • Phone: 718-460-6868
  • Fax: 718-460-2112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number057991
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number057616
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number048211
License Number StateNY

VIII. Authorized Official

Name: DR. JUN SONG
Title or Position: DENTIST
Credential: DDS,MMSC
Phone: 718-460-6868