Provider Demographics
NPI:1356920060
Name:CHANG, DILLON (DMD)
Entity type:Individual
Prefix:DR
First Name:DILLON
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 RIDGE AVE UNIT 301
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-3390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10725 SE 256TH ST STE 1
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-8285
Practice Address - Country:US
Practice Address - Phone:253-854-2714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2022-07-02
Deactivation Date:2022-04-22
Deactivation Code:
Reactivation Date:2022-07-01
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE61303625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program