Healthcare Provider Details

I. General information

NPI: 1114377009
Provider Name (Legal Business Name): LAUREN SHIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 EL CHICO TRL STE 101
WILLOW PARK TX
76087-8864
US

IV. Provider business mailing address

10513 BROOKSHIRE RD
FORT WORTH TX
76126-2641
US

V. Phone/Fax

Practice location:
  • Phone: 503-502-0953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number37162
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: