Provider Demographics
NPI:1922122498
Name:SHIN, JUNGWON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUNGWON
Middle Name:
Last Name:SHIN
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 1:23 WINNERS CIR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-4747
Mailing Address - Country:US
Mailing Address - Phone:518-306-4274
Mailing Address - Fax:
Practice Address - Street 1:156 QUAKER RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-1718
Practice Address - Country:US
Practice Address - Phone:518-793-2128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 0493281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice