=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417019381
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON C CHANG D.M.D.M.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 PARK ROW
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-385-9399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 PARK ROW
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-1127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-385-9399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 22DI02039500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------