Basic Information
| Provider Information | |||||||||
| NPI: | 1194914515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIN | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | HEA-SUN | ||||||||
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| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 568 | ||||||||
| Address2: | |||||||||
| City: | CORNELIUS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971130568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033528610 | ||||||||
| FaxNumber: | 5033598532 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 SE OAK ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971234245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033522354 | ||||||||
| FaxNumber: | 5033522363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | D9031 | OR | Y | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 023197 | 05 | OR | MEDICAID |