Provider Demographics
NPI:1306953690
Name:JIM S CHANG DDS INC
Entity type:Organization
Organization Name:JIM S CHANG DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-484-9776
Mailing Address - Street 1:12798 RANCH PENASQUITOS BLVD
Mailing Address - Street 2:SUITE I
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129
Mailing Address - Country:US
Mailing Address - Phone:858-484-9776
Mailing Address - Fax:858-484-0721
Practice Address - Street 1:12798 RANCH PENASQUITOS BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129
Practice Address - Country:US
Practice Address - Phone:858-484-9776
Practice Address - Fax:858-484-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty