=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740511310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEJIN SHANE SONG DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2010
-----------------------------------------------------
Last Update Date | 09/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 WASHBURNE AVE
-----------------------------------------------------
City | PAYNESVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56362-1640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-243-2175
-----------------------------------------------------
Fax | 320-243-8158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 WASHBURNE AVENUE
-----------------------------------------------------
City | PAYNESVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-243-2175
-----------------------------------------------------
Fax | 320-243-8158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D13182
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------