MEDICARE: CHARLES SHIM 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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	56225	CA
3	122300000X	Dentist	56225	CA

General Provider Information

NPI Number	:	1902006554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES SHIM D.D.S.

Provider Business Mailing Address
First Line	:	3288 E ANAHEIM ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3818
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3288 E ANAHEIM ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3818
Country	:	US
Telephone Number	:	213-219-7635
Fax Number	:

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

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	12/02/2014

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