Healthcare Provider Details

I. General information

NPI: 1417398405
Provider Name (Legal Business Name): CHANG MIN RICHARD YIM DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST # B854
NEWARK NJ
07103-2495
US

IV. Provider business mailing address

7001 ARLINGTON RD
BETHESDA MD
20814-5405
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-7462
  • Fax: 973-972-7322
Mailing address:
  • Phone: 215-840-5782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number16977
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: