Healthcare Provider Details

I. General information

NPI: 1790011609
Provider Name (Legal Business Name): YOUNG TAE SHIM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 PREMIERE PKWY STE 175B
DULUTH GA
30097-5258
US

IV. Provider business mailing address

2953 SPRINGBLUFF LN
BUFORD GA
30519-4195
US

V. Phone/Fax

Practice location:
  • Phone: 404-910-9060
  • Fax:
Mailing address:
  • Phone: 404-512-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN13999
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number31033
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: