=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659401750
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YONG JIN SONG DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 01/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10009 NE HAZEL DELL AVE
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-574-3070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 SE BASELINE ST STE C
-----------------------------------------------------
City | HILLSBORO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97123-4149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-648-6054
-----------------------------------------------------
Fax | 503-648-6099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9772
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D8398
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------