Provider Demographics
NPI:1851078984
Name:SHIN, KELLY (DDS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13910 45TH PL NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4564
Mailing Address - Country:US
Mailing Address - Phone:763-442-3950
Mailing Address - Fax:
Practice Address - Street 1:580 WOODBURY DR STE 300
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4949
Practice Address - Country:US
Practice Address - Phone:651-731-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND153601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice