=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033571203
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISCOUNT DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2016
-----------------------------------------------------
Last Update Date | 03/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14210 ROOSEVELT AVE # 8
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-6046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-460-6868
-----------------------------------------------------
Fax | 718-460-2112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14210 ROOSEVELT AVE # 8
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11354-6046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-460-6868
-----------------------------------------------------
Fax | 718-460-2112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JUN SONG
-----------------------------------------------------
Credential | DDS,MMSC
-----------------------------------------------------
Telephone | 718-460-6868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 057991
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 057616
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 048211
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------