Provider Demographics
NPI:1245672799
Name:SHIN, EUN SUP (DMD)
Entity type:Individual
Prefix:
First Name:EUN SUP
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 3RD AVE APT 112
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1490
Mailing Address - Country:US
Mailing Address - Phone:805-231-6067
Mailing Address - Fax:
Practice Address - Street 1:1416 NW 46TH ST STE 106
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4622
Practice Address - Country:US
Practice Address - Phone:206-783-0330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18563591223G0001X
WADE60476969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice