Provider Demographics
NPI:1558656785
Name:SHIN, TONG PHILLIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:TONG
Middle Name:PHILLIP
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 1:1101 DAVID AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFIC GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:93950-5407
Mailing Address - Country:US
Mailing Address - Phone:831-601-3313
Mailing Address - Fax:
Practice Address - Street 1:5432 E SOUTHERN AVE STE 108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2772
Practice Address - Country:US
Practice Address - Phone:480-807-8100
Practice Address - Fax:480-325-8014
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008238122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist