Healthcare Provider Details

I. General information

NPI: 1083192884
Provider Name (Legal Business Name): CHANG & PHAN DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 HUNGERFORD DR STE 100
ROCKVILLE MD
20850-5102
US

IV. Provider business mailing address

3517 DOC BERLIN DR
SILVER SPRING MD
20906-1151
US

V. Phone/Fax

Practice location:
  • Phone: 240-381-7814
  • Fax:
Mailing address:
  • Phone: 240-381-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14020
License Number StateMD

VIII. Authorized Official

Name: DR. CAROLYN SOOJIN CHANG
Title or Position: MANAGING MEMBER
Credential: DMD
Phone: 240-381-7814