Provider Demographics
NPI:1114418571
Name:CHANG, JEEMIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEEMIN
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 COLUMBIA PIKE STE A
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-5867
Mailing Address - Country:US
Mailing Address - Phone:703-671-5437
Mailing Address - Fax:
Practice Address - Street 1:1775 GRAND CONCOURSE FL 6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-8202
Practice Address - Country:US
Practice Address - Phone:413-736-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857923122300000X
CT130681223P0221X
390200000X
VA04014180711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program