Provider Demographics
NPI:1528184207
Name:CHANG, SUNG E (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUNG
Middle Name:E
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 1:7962 INLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1799
Mailing Address - Country:US
Mailing Address - Phone:763-420-4421
Mailing Address - Fax:
Practice Address - Street 1:12000 ELM CREEK BLVD N
Practice Address - Street 2:SUITE #220
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7073
Practice Address - Country:US
Practice Address - Phone:763-420-4421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND113411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND11341OtherSTATE DENTAL LICENSE