Provider Demographics
NPI:1528216629
Name:SHIN, HYUN SAM (DDS)
Entity Type:Individual
Prefix:
First Name:HYUN SAM
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 1:360 E SOUTH WATER STREET
Mailing Address - Street 2:APT 4403
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-4155
Mailing Address - Country:US
Mailing Address - Phone:323-854-1800
Mailing Address - Fax:
Practice Address - Street 1:1264B N LAKE ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-2453
Practice Address - Country:US
Practice Address - Phone:630-801-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027805122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist