Provider Demographics
NPI:1487039897
Name:SHIM, SOOYEON (DMD)
Entity Type:Individual
Prefix:
First Name:SOOYEON
Middle Name:
Last Name:SHIM
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 1:4410 SE 82ND AVE STE 2050
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2955
Mailing Address - Country:US
Mailing Address - Phone:503-771-0081
Mailing Address - Fax:503-772-2272
Practice Address - Street 1:4410 SE 82ND AVE STE 2050
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2955
Practice Address - Country:US
Practice Address - Phone:503-771-0081
Practice Address - Fax:503-772-2272
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD102901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice