Healthcare Provider Details

I. General information

NPI: 1376850917
Provider Name (Legal Business Name): PETER SHIN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 68TH ST
NEW YORK NY
10065-4870
US

IV. Provider business mailing address

240 W 116TH ST
NEW YORK NY
10026-2431
US

V. Phone/Fax

Practice location:
  • Phone: 212-746-5190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number055494
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: