Provider Demographics
NPI:1952080152
Name:SHIN, YANG SUN
Entity type:Individual
Prefix:
First Name:YANG SUN
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3693 KIDRON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KIDRON
Mailing Address - State:OH
Mailing Address - Zip Code:44636
Mailing Address - Country:US
Mailing Address - Phone:330-857-0144
Mailing Address - Fax:
Practice Address - Street 1:3693 KIDRON RD
Practice Address - Street 2:SUITE A
Practice Address - City:KIDRON
Practice Address - State:OH
Practice Address - Zip Code:44636
Practice Address - Country:US
Practice Address - Phone:330-857-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.0276181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program