Healthcare Provider Details

I. General information

NPI: 1881933190
Provider Name (Legal Business Name): MIKE CHANG DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2013
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 BANCROFT AVE
SAN LEANDRO CA
94577-2904
US

IV. Provider business mailing address

680 BANCROFT AVE
SAN LEANDRO CA
94577-2904
US

V. Phone/Fax

Practice location:
  • Phone: 510-569-0218
  • Fax: 510-569-9714
Mailing address:
  • Phone: 510-569-0218
  • Fax: 510-569-9714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. HSIU-CHAAI MIKE CHANG
Title or Position: OWNER
Credential:
Phone: 510-569-0218