Provider Demographics
NPI:1013913342
Name:CHANG, RANDY (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:RANDOLPH
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:7300 N WESTERN AVE
Mailing Address - Street 2:STE J
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1833
Mailing Address - Country:US
Mailing Address - Phone:773-338-8433
Mailing Address - Fax:773-338-8434
Practice Address - Street 1:916 N GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2240
Practice Address - Country:US
Practice Address - Phone:847-336-8200
Practice Address - Fax:847-336-8203
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA485871223G0001X
TNDS78741223G0001X
IL019-0255891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
73-1733714OtherFED TAX ID
IL019-025589OtherLICENSE #
TNDS7874OtherLICENSE #
CA48587OtherLICENSE #
CA48587OtherLICENSE #