Provider Demographics
NPI:1790011609
Name:SHIM, YOUNG TAE (DMD)
Entity Type:Individual
Prefix:DR
First Name:YOUNG
Middle Name:TAE
Last Name:SHIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2953 SPRINGBLUFF LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4195
Mailing Address - Country:US
Mailing Address - Phone:404-512-0760
Mailing Address - Fax:
Practice Address - Street 1:2925 PREMIERE PKWY STE 175B
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5258
Practice Address - Country:US
Practice Address - Phone:404-910-9060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN13999122300000X
TX31033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist