Provider Demographics
NPI:1457876963
Name:SHIN, LAUREL MIRA (DMD)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:MIRA
Last Name:SHIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 N CENTRAL EXPY APT 1410
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-5395
Mailing Address - Country:US
Mailing Address - Phone:702-904-0480
Mailing Address - Fax:
Practice Address - Street 1:2702 S BUCKNER BLVD STE 120
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6700
Practice Address - Country:US
Practice Address - Phone:469-399-6664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX368391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics