Provider Demographics
NPI:1952698615
Name:SHIN, JISOO (DDS)
Entity type:Individual
Prefix:
First Name:JISOO
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1799 N FRY RD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-3347
Mailing Address - Country:US
Mailing Address - Phone:917-748-5926
Mailing Address - Fax:
Practice Address - Street 1:6295 BISSONNET ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-6809
Practice Address - Country:US
Practice Address - Phone:713-777-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0104511223G0001X
TX279221223G0001X
NY0556441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice