Provider Demographics
NPI:1205057379
Name:SHIN, ANDREW WOOCHUL (DDS)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WOOCHUL
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 1:15080 7TH ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:760-243-5410
Mailing Address - Fax:760-243-1459
Practice Address - Street 1:15080 7TH ST
Practice Address - Street 2:SUITE 7
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-243-5410
Practice Address - Fax:760-243-1459
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34213122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist