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General NPI Number Information
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NPI Number | 1194193094
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Entity Type | Organization
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Legal Business Name | SPH BRIDGEPORT, LLC
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Dates
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Enumeration Date | 09/09/2015
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Last Update Date | 09/09/2015
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Provider Practice Location Address
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Address Line | 161 BOSTON AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06610-1662
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Country | US
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Telephone | 203-873-0598
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Fax | 203-873-0602
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Provider Business Mailing Address
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Address Line | 161 BOSTON AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06610-1662
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Country | US
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Telephone | 203-873-0598
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Fax | 203-873-0602
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Authorized Official
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Title or Position | OWNER
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Name | DR. KIGONS SONG
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Credential | DDS
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Telephone | 646-369-6918
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | NULL
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State | NULL
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