Provider Demographics
NPI:1780011189
Name:COLUMBIA DENTAL GROUP
Entity Type:Organization
Organization Name:COLUMBIA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-453-5436
Mailing Address - Street 1:1807 WILSHIRE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5652
Mailing Address - Country:US
Mailing Address - Phone:310-453-5436
Mailing Address - Fax:
Practice Address - Street 1:1807 WILSHIRE BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5652
Practice Address - Country:US
Practice Address - Phone:310-453-5436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55758122300000X
CA55347122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty