Provider Demographics
NPI:1851457428
Name:BENJAMIN L CHANG, DDS PS
Entity Type:Organization
Organization Name:BENJAMIN L CHANG, DDS PS
Other - Org Name:GREENLAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:206-547-5647
Mailing Address - Street 1:4701 MIDVALE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6641
Mailing Address - Country:US
Mailing Address - Phone:206-547-5647
Mailing Address - Fax:206-545-9291
Practice Address - Street 1:4701 MIDVALE AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6641
Practice Address - Country:US
Practice Address - Phone:206-547-5647
Practice Address - Fax:206-545-9291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE83741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty