Provider Demographics
NPI:1447517727
Name:SONG, MONICA (DMD, MPH)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 HUDSON AVE
Mailing Address - Street 2:506
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3066
Mailing Address - Country:US
Mailing Address - Phone:734-883-4406
Mailing Address - Fax:
Practice Address - Street 1:432 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-1343
Practice Address - Country:US
Practice Address - Phone:718-618-7564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-11
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist