MEDICARE: DR. RICHARD SONG

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	22DI02892700	NJ

General Provider Information

NPI Number	:	1265162515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD SONG

Provider Business Mailing Address
First Line	:	160 MORGAN ST APT 1504
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07302-6254
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3123 KENNEDY BLVD
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-2378
Country	:	US
Telephone Number	:	201-662-0662
Fax Number	:

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

Provider Enumeration Date	:	06/10/2022
Last Update Date	:	06/10/2022

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Directions to “ DR. RICHARD SONG ” Practice Location

Language	Start Address	Practice Location

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