Provider Demographics
NPI:1255673059
Name:SHIN, SARAH L (DMD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:L
Last Name:SHIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:
Practice Address - Street 1:3630 AUSTIN BLUFFS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6663
Practice Address - Country:US
Practice Address - Phone:719-304-5400
Practice Address - Fax:719-304-5409
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002029981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000145039Medicaid
CODEN.00202998OtherCO DENTAL LICENSE