MEDICARE: DAE H SONG DDS INC

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	122300000X	Dentist	25630	CA

General Provider Information

NPI Number	:	1831211820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAE H SONG DDS INC

Provider Business Mailing Address
First Line	:	3129 N SAN FERNANDO RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-1412
Country	:	US
Telephone Number	:	323-257-7744
Fax Number	:	323-257-5430

Provider Business Practice Location Address
First Line	:	3129 N SAN FERNANDO RD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-1412
Country	:	US
Telephone Number	:	323-257-7744
Fax Number	:	323-257-5430

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAE H SONG
Credential	:	D.D.S
Telephone Number	:	323-257-7744

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	07/01/2008

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