Healthcare Provider Details

I. General information

NPI: 1548043284
Provider Name (Legal Business Name): SHI & PAN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12305 120TH AVE NE STE G
KIRKLAND WA
98034-6921
US

IV. Provider business mailing address

1321 5TH LN
KIRKLAND WA
98033-5667
US

V. Phone/Fax

Practice location:
  • Phone: 425-588-3899
  • Fax:
Mailing address:
  • Phone: 310-845-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JIAYU SHI
Title or Position: ORTHODONTIST
Credential: DDS, PHD
Phone: 310-845-5276