Basic Information
| Provider Information | |||||||||
| NPI: | 1164599569 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | LIANSHENG | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | DIVISION OF OMS L-7073, MC1720 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060301720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792583 | ||||||||
| FaxNumber: | 8606791702 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | DIVISION OF OMS L-7073, MC1720 | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060301720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606792583 | ||||||||
| FaxNumber: | 8606791702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 03/07/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204E00000X | 010234 | CT | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 1223S0112X | 010234 | CT | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.