Provider Demographics
NPI:1518307610
Name:CHANG, JOHN WILLIAM KM (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN WILLIAM
Middle Name:KM
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 1:95-1105 AINAMAKUA DR
Mailing Address - Street 2:STE #202
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-6313
Mailing Address - Country:US
Mailing Address - Phone:808-445-6272
Mailing Address - Fax:808-495-0582
Practice Address - Street 1:95-1105 AINAMAKUA DR
Practice Address - Street 2:STE #202
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-6313
Practice Address - Country:US
Practice Address - Phone:808-445-6272
Practice Address - Fax:808-495-0582
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013022282122300000X
HIDT-25431223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist