Provider Demographics
NPI:1639287576
Name:CHANG, MILLIE MARY (DDS)
Entity Type:Individual
Prefix:
First Name:MILLIE
Middle Name:MARY
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 1:3959 CHADWICK DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-4810
Mailing Address - Country:US
Mailing Address - Phone:317-569-0281
Mailing Address - Fax:
Practice Address - Street 1:8136 BASH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2000
Practice Address - Country:US
Practice Address - Phone:317-577-6453
Practice Address - Fax:317-577-6456
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010347A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200421250Medicaid