Provider Demographics
NPI:1811379019
Name:CHANG, LISA (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
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 1:3500 SHERIDAN DR # 1548
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14226-1548
Mailing Address - Country:US
Mailing Address - Phone:716-655-5000
Mailing Address - Fax:
Practice Address - Street 1:3557 UNION RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-5123
Practice Address - Country:US
Practice Address - Phone:716-651-0099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058763-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04575077Medicaid