MEDICARE: BRYAN WONTAEK SHIN

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	1223P0221X	Pediatric Dentistry	12014784A	IN

General Provider Information

NPI Number	:	1689362204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN WONTAEK SHIN

Provider Business Mailing Address
First Line	:	9723 NORTHFORK DR
Second Line	:
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-8334
Country	:	US
Telephone Number	:	615-707-0330
Fax Number	:

Provider Business Practice Location Address
First Line	:	13760 LAKERIDGE DR
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46037-7608
Country	:	US
Telephone Number	:	317-588-2575
Fax Number	:

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

Provider Enumeration Date	:	05/01/2023
Last Update Date	:	07/17/2025

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Directions to “ BRYAN WONTAEK SHIN ” Practice Location

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