Healthcare Provider Details

I. General information

NPI: 1356559876
Provider Name (Legal Business Name): MYUNG W CHANG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD 4TH FLOOR, SOUTH PAVILION
PHILADELPHIA PA
19104-5127
US

IV. Provider business mailing address

3400 CIVIC CENTER BLVD 4TH FLOOR, SOUTH PAVILION
PHILADELPHIA PA
19104-5127
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3580
  • Fax:
Mailing address:
  • Phone: 215-662-3580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDS041128
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: