Provider Demographics
NPI:1760516736
Name:SHIN, YONGJEAN (DDS)
Entity Type:Individual
Prefix:
First Name:YONGJEAN
Middle Name:
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 1:1739 S EUCLID AVE
Mailing Address - Street 2:STE A
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-5831
Mailing Address - Country:US
Mailing Address - Phone:909-983-9325
Mailing Address - Fax:909-467-9956
Practice Address - Street 1:1739 S EUCLID AVE
Practice Address - Street 2:STE A
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-5831
Practice Address - Country:US
Practice Address - Phone:909-983-9325
Practice Address - Fax:909-467-9956
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49670OtherDENTICAL RENDERING PROVID