=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245870765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILIP CHANG DDS DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2020
-----------------------------------------------------
Last Update Date | 09/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1611 CRENSHAW BLVD STE C
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90501-7124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-791-7108
-----------------------------------------------------
Fax | 310-791-7142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1611 CRENSHAW BLVD STE C
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90501-7124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-731-7096
-----------------------------------------------------
Fax | 424-731-7042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. PHILIP MINSUK CHANG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 424-731-7096
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------