=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184430985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIN & KANG, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 570 E VIRGINIA WAY
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-3910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-255-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26149 PARK AVE UNIT 1
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-6128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MYUNG SHIK SHIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-328-9713
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------