Provider Demographics
NPI:1932367596
Name:SHIN, KIWON KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIWON
Middle Name:KENNETH
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 1:29 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-1320
Mailing Address - Country:US
Mailing Address - Phone:516-625-2929
Mailing Address - Fax:516-625-2558
Practice Address - Street 1:29 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1320
Practice Address - Country:US
Practice Address - Phone:516-625-2929
Practice Address - Fax:516-625-2558
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist