Provider Demographics
NPI:1215997218
Name:CHANG, MICHAEL W (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
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 1:14405 W COLFAX AVE # 142
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80401-3247
Mailing Address - Country:US
Mailing Address - Phone:720-325-5989
Mailing Address - Fax:
Practice Address - Street 1:14405 W COLFAX AVE # 142
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80401-3247
Practice Address - Country:US
Practice Address - Phone:720-325-5989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO89121223G0001X
NJ22DI022676001223G0001X
NY0513481223G0001X
MD139931223G0001X
VA04014123591223G0001X
DCDEN10008101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02558294OtherNEW YORK MEDICAID
CO74405519Medicaid