Healthcare Provider Details

I. General information

NPI: 1548728181
Provider Name (Legal Business Name): ELAINE T SHIM DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2019
Last Update Date: 03/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26741 PORTOLA PKWY STE 1D
FOOTHILL RANCH CA
92610-1762
US

IV. Provider business mailing address

19011 ANTIOCH DR
IRVINE CA
92603-3306
US

V. Phone/Fax

Practice location:
  • Phone: 949-581-4908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELAINE SHIM
Title or Position: OWNER
Credential: DDS
Phone: 702-373-0221