=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770079485
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEEJEONG SON DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2018
-----------------------------------------------------
Last Update Date | 08/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 KNEELAND ST
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-361-3655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 OVERLOOK RIDGE TER UNIT 504
-----------------------------------------------------
City | REVERE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02151-1181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 593-613-6558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1858051
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN1858051
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------