Provider Demographics
NPI:1992922272
Name:YAN, SHI (DENTURIST)
Entity type:Individual
Prefix:
First Name:SHI
Middle Name:
Last Name:YAN
Suffix:
Gender:M
Credentials:DENTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SE OLD OLYMPIC HWY
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-7731
Mailing Address - Country:US
Mailing Address - Phone:360-427-1784
Mailing Address - Fax:360-427-1818
Practice Address - Street 1:3100 SE OLD OLYMPIC HWY
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7731
Practice Address - Country:US
Practice Address - Phone:360-427-1784
Practice Address - Fax:360-427-1818
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN00000236122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5035415Medicaid
WA5035415Medicare ID - Type UnspecifiedDSHS ID #