MEDICARE: DR. ISSE SONG DENTAL OFFICE

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	DN11703	FL

General Provider Information

NPI Number	:	1659319655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. ISSE SONG DENTAL OFFICE

Provider Business Mailing Address
First Line	:	12554 S JOHN YOUNG PKWY
Second Line	:	#104
City	:	ORLANDO
State	:	FL
Zip	:	32837-4004
Country	:	US
Telephone Number	:	407-888-1088
Fax Number	:	407-888-1889

Provider Business Practice Location Address
First Line	:	12554 S JOHN YOUNG PKWY
Second Line	:	#104
City	:	ORLANDO
State	:	FL
Zip	:	32837-4004
Country	:	US
Telephone Number	:	407-888-1088
Fax Number	:	407-888-1889

Authorized Official
Title or Position	:	D.M.D., PH. D.,FAGD/ DOCTOR
Name	:	ISSE SONG
Credential	:	D.M.D
Telephone Number	:	407-888-1088

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	08/22/2020

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Directions to “DR. ISSE SONG DENTAL OFFICE ” Practice Location

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