=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346529484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DENTISTRY OF DR JESSICA SHIN, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2011
-----------------------------------------------------
Last Update Date | 03/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 AVIATION RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-798-5696
-----------------------------------------------------
Fax | 518-745-6854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 AVIATION RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-798-5696
-----------------------------------------------------
Fax | 518-745-6854
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. JUNGWON SHIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 518-798-5696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 49328
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------