Provider Demographics
NPI:1336302728
Name:CHANG, TINA (DMD MD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:DMD MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 WILSHIRE BLVD # W160
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-1003
Mailing Address - Country:US
Mailing Address - Phone:310-268-3776
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD # W160
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51324A996211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery