=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275105033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. MICHELLE G. CHANG DMD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2021
-----------------------------------------------------
Last Update Date | 07/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1620 DUVALL AVE NE STE A
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98059-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-271-6002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 DUVALL AVE NE STE A
-----------------------------------------------------
City | RENTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98059-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-271-6002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | AARON FORDHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-736-3739
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------