Provider Demographics
NPI:1114231008
Name:CHANG, CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14343 41ST AVE
Mailing Address - Street 2:APT.6F
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-1864
Mailing Address - Country:US
Mailing Address - Phone:646-667-7633
Mailing Address - Fax:
Practice Address - Street 1:14343 41ST AVE
Practice Address - Street 2:APT.6F
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1864
Practice Address - Country:US
Practice Address - Phone:646-667-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054987-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist