Healthcare Provider Details

I. General information

NPI: 1528116712
Provider Name (Legal Business Name): JAEHEE L SHIM D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LEBANON AVE SUITE 104
BELLEVILLE IL
62221-2491
US

IV. Provider business mailing address

1600 LEBANON AVE SUITE 104
BELLEVILLE IL
62221-2491
US

V. Phone/Fax

Practice location:
  • Phone: 618-239-6151
  • Fax:
Mailing address:
  • Phone: 618-239-6151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19A-15414
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: