Provider Demographics
NPI:1710075213
Name:CHANG, RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
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 1:121 112TH AVE NE STE D
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-5807
Mailing Address - Country:US
Mailing Address - Phone:425-688-8558
Mailing Address - Fax:425-688-8559
Practice Address - Street 1:121 112TH AVE NE STE D
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5807
Practice Address - Country:US
Practice Address - Phone:425-688-8558
Practice Address - Fax:425-688-8559
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000077171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5024351Medicaid