Provider Demographics
NPI:1396886727
Name:SHIN, RICHARD C (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:SHIN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:CHONG
Other - Middle Name:YUN
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:4701 RANDOLPH RD STE 108
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:301-770-7770
Mailing Address - Fax:301-770-7776
Practice Address - Street 1:4701 RANDOLPH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2257
Practice Address - Country:US
Practice Address - Phone:301-770-7770
Practice Address - Fax:301-770-7776
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD136851223X0400X
IL0190272351223X0400X
TN93961223X0400X
CA569931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD085244900Medicaid
MD085244900Medicaid