Healthcare Provider Details

I. General information

NPI: 1255987780
Provider Name (Legal Business Name): BRIGHT JESUK CHANG DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2019
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COLLEGE ST
PORTLAND ME
04103-2617
US

IV. Provider business mailing address

340 CLARKS POND PKWY APT 105
SOUTH PORTLAND ME
04106-7923
US

V. Phone/Fax

Practice location:
  • Phone: 207-221-4747
  • Fax:
Mailing address:
  • Phone: 334-207-2128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDEN4942
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD0006681-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: