Healthcare Provider Details

I. General information

NPI: 1679504310
Provider Name (Legal Business Name): ELAINE T SHIM DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
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: 702-373-0221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44541
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: