Provider Demographics
NPI:1225662026
Name:CHANG, IRENE DAN YI
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:DAN YI
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 ALA MOANA BLVD APT 3815
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-1627
Mailing Address - Country:US
Mailing Address - Phone:408-691-3579
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BLVD STE 7300
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4905
Practice Address - Country:US
Practice Address - Phone:808-523-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1069071223G0001X
HIDT-3037122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice