Provider Demographics
NPI:1932611035
Name:CHANG, SOO JIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SOO
Middle Name:JIN
Last Name:CHANG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 S SERRANO AVE APT 705
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-7202
Mailing Address - Country:US
Mailing Address - Phone:213-910-4084
Mailing Address - Fax:
Practice Address - Street 1:8501 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3501
Practice Address - Country:US
Practice Address - Phone:310-670-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA624331223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics