Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 010234 | CT |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 010234 | CT |
NPI | 1164599569 |
---|---|
Provider Name | Liansheng Song |
First Address | Farmington, CT 06030-1720 |
Second Address | Farmington, CT 06030-1720 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2006 |
Last Update Date | 07/03/2013 |