Provider Demographics
NPI:1811413610
Name:BYUN, SHANE SANGJUN (DMD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:SANGJUN
Last Name:BYUN
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 1:622 S BROADWAY APT 116
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2976
Mailing Address - Country:US
Mailing Address - Phone:310-972-0999
Mailing Address - Fax:
Practice Address - Street 1:650 W BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1510
Practice Address - Country:US
Practice Address - Phone:410-706-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16541122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist