MEDICARE: MODERN E DENTAL

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	1223G0001X	General Practice Dentistry	049968	NY

General Provider Information

NPI Number	:	1104090471
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN E DENTAL

Provider Business Mailing Address
First Line	:	4823 LITTLE NECK PKWY
Second Line	:
City	:	LITTLE NECK
State	:	NY
Zip	:	11362-1432
Country	:	US
Telephone Number	:	718-281-1282
Fax Number	:

Provider Business Practice Location Address
First Line	:	4823 LITTLE NECK PKWY
Second Line	:
City	:	LITTLE NECK
State	:	NY
Zip	:	11362-1432
Country	:	US
Telephone Number	:	718-281-1282
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. GRACE E SHIN
Credential	:	D.D.S
Telephone Number	:	718-281-1282

Provider Enumeration Date	:	04/17/2008
Last Update Date	:	04/17/2008

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