MEDICARE: SHINY STUDIO PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1073155784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHINY STUDIO PLLC

Provider Business Mailing Address
First Line	:	708 GLEN ABBEY DR
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-1378
Country	:	US
Telephone Number	:	347-899-5601
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 INDUSTRIAL AVE
Second Line	:
City	:	AZLE
State	:	TX
Zip	:	76020-2934
Country	:	US
Telephone Number	:	817-270-3700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SO CHUNG
Credential	:
Telephone Number	:	347-899-5601

Provider Enumeration Date	:	10/14/2019
Last Update Date	:	10/14/2019

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