Provider Demographics
NPI:1588236673
Name:SHIM, ALBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:
Last Name:SHIM
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 1:2530 NW MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-5510
Mailing Address - Country:US
Mailing Address - Phone:541-837-1713
Mailing Address - Fax:
Practice Address - Street 1:2530 NW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5510
Practice Address - Country:US
Practice Address - Phone:541-837-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11729122300000X, 1223G0001X
UT12363998-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist