Provider Demographics
NPI:1922131978
Name:CHANG, PAUL S (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
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:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770
Mailing Address - Country:US
Mailing Address - Phone:626-573-8261
Mailing Address - Fax:626-573-8036
Practice Address - Street 1:8150 E GARVEY AVE
Practice Address - Street 2:#109
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770
Practice Address - Country:US
Practice Address - Phone:626-573-8261
Practice Address - Fax:626-573-8036
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52322122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA52322Medicaid
CA52322Medicaid