Provider Demographics
NPI:1982058632
Name:SHIN, JENNIFER HAE SU (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:HAE SU
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 1:940 ELDEN AVE UNIT 305
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-5845
Mailing Address - Country:US
Mailing Address - Phone:213-810-1318
Mailing Address - Fax:
Practice Address - Street 1:17024 CLARK AVE STE C
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-5700
Practice Address - Country:US
Practice Address - Phone:213-810-1318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS102028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist