=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922122498
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUNGWON SHIN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 QUAKER RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-793-2128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 WINNERS CIR
-----------------------------------------------------
City | SARATOGA SPRINGS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12866-4747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-306-4274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 50 049328
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------