Healthcare Provider Details

I. General information

NPI: 1770968778
Provider Name (Legal Business Name): SHINJAE YOO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 07/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 S MAIN ST
NEW BRITAIN CT
06051-3516
US

IV. Provider business mailing address

299 COLT HWY APT 113
FARMINGTON CT
06032-3082
US

V. Phone/Fax

Practice location:
  • Phone: 860-645-0111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11440
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: