Provider Demographics
NPI:1780896399
Name:CHANG, BENJAMIN JONAH RODA (DTCM, ADS, LAC)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JONAH RODA
Last Name:CHANG
Suffix:
Gender:M
Credentials:DTCM, ADS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2281 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9555
Mailing Address - Country:US
Mailing Address - Phone:360-220-1821
Mailing Address - Fax:
Practice Address - Street 1:2801 MERIDIAN ST STE 102
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-2400
Practice Address - Country:US
Practice Address - Phone:360-756-5866
Practice Address - Fax:360-734-0843
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002946171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1588313639Medicaid