Provider Demographics
NPI:1578948725
Name:SHIN, JAE W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:W
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 1:618TH DENTAL CO, CARIUS DENTAL CLINIC BLDG# P3020 ATTN:
Mailing Address - Street 2:CREDENTIAL OFFICE
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96271
Mailing Address - Country:US
Mailing Address - Phone:315-737-9186
Mailing Address - Fax:
Practice Address - Street 1:618TH DENTAL CO, CARIUS DENTAL CLINIC BLDG# P3020 ATTN:
Practice Address - Street 2:CREDENTIAL OFFICE
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5245
Practice Address - Country:US
Practice Address - Phone:315-737-9186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9094721-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist