Provider Demographics
NPI:1831276641
Name:CHANG, BRICE (DDS)
Entity type:Individual
Prefix:DR
First Name:BRICE
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PACIFIC AVE
Mailing Address - Street 2:P.O. BOX 4370
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415
Mailing Address - Country:US
Mailing Address - Phone:541-469-0192
Mailing Address - Fax:541-459-5192
Practice Address - Street 1:350 PACIFIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-0241
Practice Address - Country:US
Practice Address - Phone:541-469-0192
Practice Address - Fax:360-892-8902
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD000093001223G0001X
ORD8019122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5044482Medicaid