MEDICARE: AILIN SHAN

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	1223G0001X	General Practice Dentistry	0401410938	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9180406	OTHER	VA	DORAL

General Provider Information

NPI Number	:	1568439859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AILIN SHAN

Provider Business Mailing Address
First Line	:	415 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-3111
Country	:	US
Telephone Number	:	719-546-3333
Fax Number	:

Provider Business Practice Location Address
First Line	:	5322 CHAMBERLAYNE AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23227-2203
Country	:	US
Telephone Number	:	804-266-5040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2006
Last Update Date	:	07/08/2007

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Directions to “ AILIN SHAN ” Practice Location

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