Provider Demographics
NPI:1306969415
Name:CHANG, ROBERT (DDS, MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PALISADES DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-6433
Mailing Address - Country:US
Mailing Address - Phone:518-348-0634
Mailing Address - Fax:518-426-3221
Practice Address - Street 1:5 PALISADES DR
Practice Address - Street 2:SUITE 210
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6433
Practice Address - Country:US
Practice Address - Phone:518-348-0634
Practice Address - Fax:518-426-3221
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0535891223S0112X
NY247005204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02926121Medicaid