Provider Demographics
NPI:1679504310
Name:SHIM, ELAINE T (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:T
Last Name:SHIM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19011 ANTIOCH DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92603-3306
Mailing Address - Country:US
Mailing Address - Phone:702-373-0221
Mailing Address - Fax:
Practice Address - Street 1:26741 PORTOLA PKWY STE 1D
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-1762
Practice Address - Country:US
Practice Address - Phone:949-581-4908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445411223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice