Provider Demographics
NPI:1669504221
Name:SHIM, JAE MYUNG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:MYUNG
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 1:1800 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-3582
Mailing Address - Country:US
Mailing Address - Phone:847-336-4180
Mailing Address - Fax:847-336-4190
Practice Address - Street 1:1800 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-3582
Practice Address - Country:US
Practice Address - Phone:847-336-4180
Practice Address - Fax:847-336-4190
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004816Medicaid