Provider Demographics
NPI:1245354695
Name:SHIM, ROY D (DDS)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:D
Last Name:SHIM
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 1:8507 N 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4919
Mailing Address - Country:US
Mailing Address - Phone:602-973-0325
Mailing Address - Fax:480-454-7111
Practice Address - Street 1:6135 N 35TH AVE STE 135
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1952
Practice Address - Country:US
Practice Address - Phone:602-973-0325
Practice Address - Fax:602-973-9704
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7163122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ228117Medicaid