Young Tae Shim, DMD

Primary specialty

DentistTaxonomy code 122300000X

License

31033 Issued in TX

Practice address

2925 Premiere Pkwy Ste 175B
Duluth, GA 30097-5258

Phone

(404) 910-9060

NPI assigned

Oct 27, 2009

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1256601600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1654041600000",
    "number": "1790011609",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2953 SPRINGBLUFF LN",
            "city": "BUFORD",
            "state": "GA",
            "postal_code": "305194195",
            "telephone_number": "404-512-0760"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2925 PREMIERE PKWY STE 175B",
            "city": "DULUTH",
            "state": "GA",
            "postal_code": "300975258",
            "telephone_number": "404-910-9060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SHIM",
        "first_name": "YOUNG",
        "middle_name": "TAE",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2009-10-27",
        "last_updated": "2022-06-01",
        "certification_date": "2022-06-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "GA",
            "license": "DN13999",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "TX",
            "license": "31033",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Dentist in Duluth, GA
• Providers in Duluth, GA by specialty
• Dentist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 1, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.