Provider Demographics
NPI:1104930056
Name:SHIM, EUNJUNG (DMD, MDS)
Entity type:Individual
Prefix:
First Name:EUNJUNG
Middle Name:
Last Name:SHIM
Suffix:
Gender:F
Credentials:DMD, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 MUNSEY RD
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1513
Mailing Address - Country:US
Mailing Address - Phone:201-927-7144
Mailing Address - Fax:
Practice Address - Street 1:654 AVENUE C STE 202
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3899
Practice Address - Country:US
Practice Address - Phone:201-436-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02329900122300000X
NJ0570091223P0300X
NY9363084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist