Provider Demographics
NPI:1376787663
Name:CHANG, VICKY (DDS)
Entity Type:Individual
Prefix:DR
First Name:VICKY
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10545 LA VITA CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2341
Mailing Address - Country:US
Mailing Address - Phone:415-269-3953
Mailing Address - Fax:
Practice Address - Street 1:2310 CRAVEN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136
Practice Address - Country:US
Practice Address - Phone:619-556-8240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58162122300000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program