MEDICARE: DR. KIWON KENNETH SHIN DDS

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	122300000X	Dentist	039926	NY

General Provider Information

NPI Number	:	1932367596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIWON KENNETH SHIN DDS

Provider Business Mailing Address
First Line	:	29 NORTHERN BLVD
Second Line	:
City	:	GREENVALE
State	:	NY
Zip	:	11548-1320
Country	:	US
Telephone Number	:	516-625-2929
Fax Number	:	516-625-2558

Provider Business Practice Location Address
First Line	:	29 NORTHERN BLVD
Second Line	:
City	:	GREENVALE
State	:	NY
Zip	:	11548-1320
Country	:	US
Telephone Number	:	516-625-2929
Fax Number	:	516-625-2558

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

Provider Enumeration Date	:	05/29/2008
Last Update Date	:	05/29/2008

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