Sejin Shane Song, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D13182 Issued in MN

Practice address

107 Washburne Ave
Paynesville, MN 56362-1640

Phone

(320) 243-2175

Fax

(320) 243-8158

NPI assigned

Jan 21, 2010

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1264032000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1473206400000",
    "number": "1740511310",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "107 WASHBURNE AVENUE",
            "city": "PAYNESVILLE",
            "state": "MN",
            "postal_code": "56362",
            "telephone_number": "320-243-2175",
            "fax_number": "320-243-8158"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "107 WASHBURNE AVE",
            "city": "PAYNESVILLE",
            "state": "MN",
            "postal_code": "563621640",
            "telephone_number": "320-243-2175",
            "fax_number": "320-243-8158"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SONG",
        "first_name": "SEJIN",
        "middle_name": "SHANE",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2010-01-21",
        "last_updated": "2016-09-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D13182",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Erin Salo, PHARMD
• Brandy Lee Schade
• Rebecca Lee Schmitt
• Serenity Path Inc.
• Amanda Nicole Smith, PHARMD
• Courtney Erin Stenger, DC
• Joseph Walter Stephanie, CRNA
• Lawrence Gordon Strate, M.D.,
• Bryan Stroyny, PHARM.D.
• Ronald Craig Swenson, LADC

• General Practice Dentistry in Paynesville, MN
• Providers in Paynesville, MN by specialty
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 7, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.