Provider Demographics
NPI:1003423633
Name:SHIN, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 REBA CT
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3342
Mailing Address - Country:US
Mailing Address - Phone:224-522-4908
Mailing Address - Fax:
Practice Address - Street 1:2702 W TOUHY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-3008
Practice Address - Country:US
Practice Address - Phone:773-338-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist