Healthcare Provider Details

I. General information

NPI: 1902881105
Provider Name (Legal Business Name): ELIZABETH MIL-JIN SHIN D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 ELM ST
PRINCESS ANNE MD
21853-1358
US

IV. Provider business mailing address

PO BOX 1978
SALISBURY MD
21802-1978
US

V. Phone/Fax

Practice location:
  • Phone: 410-651-5151
  • Fax: 410-651-4682
Mailing address:
  • Phone: 410-749-1015
  • Fax: 410-749-0654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number13635
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: