Healthcare Provider Details

I. General information

NPI: 1447573241
Provider Name (Legal Business Name): IVY CHANG D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 WESTWOOD AVE
RIVER VALE NJ
07675-6336
US

IV. Provider business mailing address

669 WESTWOOD AVE
RIVER VALE NJ
07675-6336
US

V. Phone/Fax

Practice location:
  • Phone: 201-664-0130
  • Fax:
Mailing address:
  • Phone: 201-666-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046700
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI19923
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI01992300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: