Provider Demographics
NPI:1306154935
Name:SHIN, DONG PYO (LAC)
Entity type:Individual
Prefix:
First Name:DONG PYO
Middle Name:
Last Name:SHIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SATELLITE BLVD STE 2370
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5067
Mailing Address - Country:US
Mailing Address - Phone:678-858-9644
Mailing Address - Fax:
Practice Address - Street 1:4500 SATELLITE BLVD STE 2370
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5067
Practice Address - Country:US
Practice Address - Phone:678-858-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13626171100000X
GA386171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist