Healthcare Provider Details

I. General information

NPI: 1356999510
Provider Name (Legal Business Name): JIN SUP SHIN DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E 58TH ST STE 912
NEW YORK NY
10022-1283
US

IV. Provider business mailing address

4117 CRESCENT ST APT 4B
LONG ISLAND CITY NY
11101-3862
US

V. Phone/Fax

Practice location:
  • Phone: 646-760-8028
  • Fax:
Mailing address:
  • Phone: 917-971-3232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number060492
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: