Healthcare Provider Details

I. General information

NPI: 1477395523
Provider Name (Legal Business Name): EVAN HOCHEUL SHIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 CHARLES ST
ROCKFORD IL
61108-1758
US

IV. Provider business mailing address

1425 ELLINWOOD AVE UNIT 539
DES PLAINES IL
60016-5275
US

V. Phone/Fax

Practice location:
  • Phone: 815-399-5181
  • Fax:
Mailing address:
  • Phone: 734-709-5350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12014482A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019.035464
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: