Healthcare Provider Details

I. General information

NPI: 1982161006
Provider Name (Legal Business Name): KEARNY CHANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 E PRENTICE AVE
GREENWOOD VILLAGE CO
80111-2744
US

IV. Provider business mailing address

8000 E PRENTICE AVE
GREENWOOD VILLAGE CO
80111-2744
US

V. Phone/Fax

Practice location:
  • Phone: 720-370-2130
  • Fax:
Mailing address:
  • Phone: 720-370-2130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number205687
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number36075
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: