Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019.032865 | IL |
NPI | 1003423633 |
---|---|
Provider Name | Andrew Shin |
First Address | Morton Grove, IL 60053-3342 |
Second Address | Chicago, IL 60645-3008 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/09/2020 |
Last Update Date | 28/09/2020 |