MEDICARE: MOON J 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	1223G0001X	General Practice Dentistry	42002	CA

General Provider Information

NPI Number	:	1548479777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOON J SONG D.D.S.

Provider Business Mailing Address
First Line	:	2242 CAMDEN AVE
Second Line	:	SUITE 101
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2029
Country	:	US
Telephone Number	:	408-718-5837
Fax Number	:	408-366-0602

Provider Business Practice Location Address
First Line	:	2242 CAMDEN AVE
Second Line	:	SUITE 101
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2029
Country	:	US
Telephone Number	:	408-718-5837
Fax Number	:	408-366-0602

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	04/10/2014

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