Provider Demographics
NPI:1215980750
Name:CHANG, PAUL (DDS)
Entity type:Individual
Prefix:MR
First Name:PAUL
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:P.O. BOX 30060
Mailing Address - Street 2:
Mailing Address - City:LAUGHLIN
Mailing Address - State:NV
Mailing Address - Zip Code:89028-0192
Mailing Address - Country:US
Mailing Address - Phone:928-234-3078
Mailing Address - Fax:928-763-8801
Practice Address - Street 1:3003 HIGHWAY 95
Practice Address - Street 2:SUITE B-33
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7860
Practice Address - Country:US
Practice Address - Phone:928-763-8750
Practice Address - Fax:928-763-8801
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ57741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA05774Medicaid
AZ898380Medicaid