Provider Demographics
NPI:1184034746
Name:CHANG, JIM S (DDS)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:S
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 1:12798 RANCHO PENASQUITOS BLVD # 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129
Mailing Address - Country:US
Mailing Address - Phone:858-484-9776
Mailing Address - Fax:858-484-0721
Practice Address - Street 1:12798 RANCHO PENASQUITOS BLVD # 1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129
Practice Address - Country:US
Practice Address - Phone:858-484-9776
Practice Address - Fax:858-484-0721
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA349421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice