Healthcare Provider Details

I. General information

NPI: 1699593780
Provider Name (Legal Business Name): EDMUND SONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9203 ROOSEVELT AVE
JACKSON HEIGHTS NY
11372-7941
US

IV. Provider business mailing address

760 BROADWAY DEPARTMENT OF DENTISTRY & OMS, SUITE 2C-319
BROOKLYN NY
11206
US

V. Phone/Fax

Practice location:
  • Phone: 516-362-1001
  • Fax:
Mailing address:
  • Phone: 718-963-8308
  • Fax: 718-963-8317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number065440
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: