Provider Demographics
NPI:1023592490
Name:SHIN, BRYAN IKSU (DDS)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:IKSU
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 1:12721 192ND PL E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8362
Mailing Address - Country:US
Mailing Address - Phone:614-364-1695
Mailing Address - Fax:
Practice Address - Street 1:927 128TH ST SW
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-6315
Practice Address - Country:US
Practice Address - Phone:425-290-6967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0254061223G0001X
WADE611038201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice