=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851790661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBIA DENTAL SPECIALTY GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2014
-----------------------------------------------------
Last Update Date | 08/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1807 WILSHIRE BLVD STE A
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-5652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-264-1711
-----------------------------------------------------
Fax | 310-453-6486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1807 WILSHIRE BLVD STE A
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90403-5652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-264-1711
-----------------------------------------------------
Fax | 310-453-6486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JENNIFER CHANG
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 310-264-1711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 59653
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 53057
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------