MEDICARE: DR. MICHAEL SOO-HYUNG SONG D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	8219	VA

General Provider Information

NPI Number	:	1235318569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL SOO-HYUNG SONG D.D.S.

Provider Business Mailing Address
First Line	:	3975 FAIR RIDGE DR
Second Line	:	SUITE #301 NORTH
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2911
Country	:	US
Telephone Number	:	703-385-5455
Fax Number	:

Provider Business Practice Location Address
First Line	:	3975 FAIR RIDGE DR
Second Line	:	SUITE #301 NORTH
City	:	FAIRFAX
State	:	VA
Zip	:	22033-2911
Country	:	US
Telephone Number	:	703-385-5455
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2007
Last Update Date	:	11/02/2007

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