Provider Demographics
NPI:1851790661
Name:COLUMBIA DENTAL SPECIALTY GROUP
Entity Type:Organization
Organization Name:COLUMBIA DENTAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-264-1711
Mailing Address - Street 1:1807 WILSHIRE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5652
Mailing Address - Country:US
Mailing Address - Phone:310-264-1711
Mailing Address - Fax:310-453-6486
Practice Address - Street 1:1807 WILSHIRE BLVD
Practice Address - Street 2:STE A
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5652
Practice Address - Country:US
Practice Address - Phone:310-264-1711
Practice Address - Fax:310-453-6486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA596531223E0200X
CA530571223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty