Healthcare Provider Details

I. General information

NPI: 1831276641
Provider Name (Legal Business Name): BRICE CHANG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 PACIFIC AVE STE 101
BROOKINGS OR
97415-0241
US

IV. Provider business mailing address

350 PACIFIC AVE P.O. BOX 4370
BROOKINGS OR
97415
US

V. Phone/Fax

Practice location:
  • Phone: 541-469-0192
  • Fax: 360-892-8902
Mailing address:
  • Phone: 541-469-0192
  • Fax: 541-459-5192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD00009300
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD8019
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: