Provider Demographics
NPI:1114171626
Name:CHANG, SANGSOON (DOM)
Entity Type:Individual
Prefix:DR
First Name:SANGSOON
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12406 NEW DAWN RD NE # RDNE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-4304
Mailing Address - Country:US
Mailing Address - Phone:505-710-7504
Mailing Address - Fax:
Practice Address - Street 1:2617 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2966
Practice Address - Country:US
Practice Address - Phone:505-710-7504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM960171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist