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General NPI Number Information
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NPI Number | 1396148771
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Entity Type | Organization
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Legal Business Name | GLENN CHANG DDS INC
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Dates
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Enumeration Date | 09/30/2014
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Last Update Date | 10/15/2014
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Provider Practice Location Address
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Address Line | 20657 GOLDEN SPRINGS DR SUITE205B
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City | DIAMOND BAR
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State | CA
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Zip | 91789-3875
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Country | US
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Telephone | 909-595-2868
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Fax | 909-569-1866
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Provider Business Mailing Address
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Address Line | 20657 GOLDEN SPRINGS DR SUITE205B
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City | DIAMOND BAR
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State | CA
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Zip | 91789-3875
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Country | US
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Telephone | 909-595-2868
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Fax | 909-569-1866
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Authorized Official
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Title or Position | PRESIDENT
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Name | GLENN CHANG
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Credential | DDS
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Telephone | 909-595-2868
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 54537
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License Number State | CA
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