Provider Demographics
NPI:1154566677
Name:PELLY CHANG,DMD,PC
Entity type:Organization
Organization Name:PELLY CHANG,DMD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-479-0079
Mailing Address - Street 1:166 WILLARD ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-1516
Mailing Address - Country:US
Mailing Address - Phone:617-479-0079
Mailing Address - Fax:
Practice Address - Street 1:166 WILLARD ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1516
Practice Address - Country:US
Practice Address - Phone:617-479-0079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty