Healthcare Provider Details

I. General information

NPI: 1609664002
Provider Name (Legal Business Name): STANFORD LEE SHIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 ORANGE ST
REDLANDS CA
92374-3206
US

IV. Provider business mailing address

25522 CARROL CT
LOMA LINDA CA
92354-3700
US

V. Phone/Fax

Practice location:
  • Phone: 909-792-7500
  • Fax: 909-792-7500
Mailing address:
  • Phone: 951-295-0856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number112326
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: