Healthcare Provider Details

I. General information

NPI: 1245672799
Provider Name (Legal Business Name): EUN SUP SHIN D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1416 NW 46TH ST STE 106
SEATTLE WA
98107-4622
US

IV. Provider business mailing address

2550 3RD AVE APT 112
SEATTLE WA
98121-1490
US

V. Phone/Fax

Practice location:
  • Phone: 206-783-0330
  • Fax:
Mailing address:
  • Phone: 805-231-6067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60476969
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1856359
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: