Provider Demographics
NPI:1356999510
Name:SHIN, JIN SUP (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JIN SUP
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 CRESCENT ST APT 4B
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3862
Mailing Address - Country:US
Mailing Address - Phone:917-971-3232
Mailing Address - Fax:
Practice Address - Street 1:133 E 58TH ST STE 912
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1283
Practice Address - Country:US
Practice Address - Phone:646-760-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0604921223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty