Provider Demographics
NPI:1245870765
Name:PHILIP CHANG DDS DENTAL CORPORATION
Entity type:Organization
Organization Name:PHILIP CHANG DDS DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:MINSUK
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:424-731-7096
Mailing Address - Street 1:1611 CRENSHAW BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-7124
Mailing Address - Country:US
Mailing Address - Phone:424-731-7096
Mailing Address - Fax:424-731-7042
Practice Address - Street 1:1611 CRENSHAW BLVD STE C
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-7124
Practice Address - Country:US
Practice Address - Phone:310-791-7108
Practice Address - Fax:310-791-7142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-13
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51048OtherGENERAL