Provider Demographics
NPI:1578335261
Name:SHIN, HANEUL
Entity Type:Individual
Prefix:
First Name:HANEUL
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 1ST ST UNIT S604
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-3045
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10440 S DE ANZA BLVD STE D1
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3018
Practice Address - Country:US
Practice Address - Phone:408-642-1775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109397122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist