Provider Demographics
NPI:1093813354
Name:CHANG, PE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PE
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:PE
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:6800 VISTA DEL NORTE RD NE
Mailing Address - Street 2:UNIT #1526
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7111 PROSPECT PL NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4309
Practice Address - Country:US
Practice Address - Phone:505-888-5131
Practice Address - Fax:505-888-5135
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0018016Medicaid
NM55120725Medicaid
NM1505220OtherUNITED CONCORDIA