MEDICARE: YAE SAM 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	1223G0001X	General Practice Dentistry	DDS104340	CA

General Provider Information

NPI Number	:	1306494000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YAE SAM SONG

Provider Business Mailing Address
First Line	:	1518 NILES ST
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93305-4806
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1518 NILES ST
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93305-4806
Country	:	US
Telephone Number	:	616-326-0766
Fax Number	:

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

Provider Enumeration Date	:	08/27/2019
Last Update Date	:	08/27/2019

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Directions to “ YAE SAM SONG ” Practice Location

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