Provider Demographics
NPI:1043490956
Name:SHIN, JICHEOL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JICHEOL
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 1:108 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7096
Mailing Address - Country:US
Mailing Address - Phone:201-497-5207
Mailing Address - Fax:
Practice Address - Street 1:460 SYLVAN AVE # 1F
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2919
Practice Address - Country:US
Practice Address - Phone:201-461-0002
Practice Address - Fax:201-816-1144
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02357800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist