=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093452047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUH YUN CHANG LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2022
-----------------------------------------------------
Last Update Date | 05/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10401 OLD GEORGETOWN RD STE 405
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-530-5909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10401 OLD GEORGETOWN RD STE 405
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20814-1911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-530-5909
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUSAN CHANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 301-530-5909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------