=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811413610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE SANGJUN BYUN DMD, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2017
-----------------------------------------------------
Last Update Date | 02/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NAVAL HEALTH CLINIC HAWAII 480 CENTRAL AVE
-----------------------------------------------------
City | PEARL HARBOR
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-473-1880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 480 CENTRAL AVE
-----------------------------------------------------
City | PEARL HARBOR
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96860-4908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-473-1880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 16541
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 16541
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------