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General NPI Number Information
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NPI Number | 1659022887
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Entity Type | Organization
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Legal Business Name | MICHAEL CHANG DENTAL CORP
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Dates
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Enumeration Date | 01/10/2022
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Last Update Date | 01/10/2022
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Provider Practice Location Address
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Address Line | 142 W BASE LINE RD STE B
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City | RIALTO
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State | CA
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Zip | 92376-3302
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Country | US
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Telephone | 909-341-5325
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Fax |
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Provider Business Mailing Address
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Address Line | 1120 S GRAND AVE APT 2612
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City | LOS ANGELES
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State | CA
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Zip | 90015-4659
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Country | US
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Telephone | 213-294-1462
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL CHANG
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Credential | DDS
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Telephone | 213-294-1462
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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