Provider Demographics
NPI:1679747885
Name:CHANG, JIN SUP (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:SUP
Last Name:CHANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5139
Mailing Address - Country:US
Mailing Address - Phone:410-271-7195
Mailing Address - Fax:
Practice Address - Street 1:400 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2410
Practice Address - Country:US
Practice Address - Phone:228-523-5103
Practice Address - Fax:228-523-4310
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA549781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice