Provider Demographics
NPI:1669858098
Name:CHANG, KWANG KYUN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KWANG
Middle Name:KYUN
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5774 OAK RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-0425
Mailing Address - Country:US
Mailing Address - Phone:480-570-3896
Mailing Address - Fax:
Practice Address - Street 1:4710 W 95TH ST UNIT B10
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2432
Practice Address - Country:US
Practice Address - Phone:480-570-3896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030376122300000X
IL0210027271223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist