Provider Demographics
NPI:1083192884
Name:CHANG & PHAN DENTAL, LLC
Entity Type:Organization
Organization Name:CHANG & PHAN DENTAL, LLC
Other - Org Name:ALL STAR PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:SOOJIN
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:240-381-7814
Mailing Address - Street 1:3517 DOC BERLIN DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-1151
Mailing Address - Country:US
Mailing Address - Phone:240-381-7814
Mailing Address - Fax:
Practice Address - Street 1:451 HUNGERFORD DR STE 100
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-5102
Practice Address - Country:US
Practice Address - Phone:240-381-7814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD140201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty