Provider Demographics
NPI:1427182658
Name:SHIN, BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 RIVER REACH CT
Mailing Address - Street 2:APT. R
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-7395
Mailing Address - Country:US
Mailing Address - Phone:312-493-7266
Mailing Address - Fax:
Practice Address - Street 1:195 UNIVERSITY PARK DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-0001
Practice Address - Country:US
Practice Address - Phone:618-650-5062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice