MEDICARE: JAEMIN 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	062257	NY
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223G0001X	General Practice Dentistry	DN1858981	MA

General Provider Information

NPI Number	:	1497376560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAEMIN SONG

Provider Business Mailing Address
First Line	:	2935 JOHN F KENNEDY BLVD APT 610
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-3881
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	145 CANAL ST FL 2
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10002-5033
Country	:	US
Telephone Number	:	917-388-3678
Fax Number	:

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

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	09/06/2023

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Directions to “ JAEMIN SONG ” Practice Location

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