MEDICARE: DR. GRACE EUN JIN SHIN D.D.S

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	:	1295724565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE EUN JIN SHIN D.D.S

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	:	718-281-2229

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	:	718-281-2229

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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