Provider Demographics
NPI:1114377009
Name:SHIN, LAUREN
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10513 BROOKSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-2641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:136 EL CHICO TRL STE 101
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76087-8864
Practice Address - Country:US
Practice Address - Phone:503-502-0953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX371621223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty