=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366871394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISSE SONG PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2013
-----------------------------------------------------
Last Update Date | 11/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12554 S JOHN YOUNG PARKWAY 104
-----------------------------------------------------
City | ORLANDO FLORIDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-888-1088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12554 S JOHN YOUNG PARKWAY 104
-----------------------------------------------------
City | ORLANDO FLORIDA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-888-1088
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ISSE SONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-888-1088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------