Provider Demographics
NPI:1669854212
Name:SHIM, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SHIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 FOREST AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1730
Mailing Address - Country:US
Mailing Address - Phone:804-893-8692
Mailing Address - Fax:804-285-1292
Practice Address - Street 1:6900 FOREST AVE STE 110
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1730
Practice Address - Country:US
Practice Address - Phone:804-893-8692
Practice Address - Fax:804-285-1292
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0442000244122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist