Provider Demographics
NPI:1396079794
Name:CHANG, SOO JIN
Entity type:Individual
Prefix:
First Name:SOO JIN
Middle Name:
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 1:39-20 GREENPOINT
Mailing Address - Street 2:6A
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104
Mailing Address - Country:US
Mailing Address - Phone:847-894-0939
Mailing Address - Fax:
Practice Address - Street 1:3920 GREENPOINT AVE
Practice Address - Street 2:6A
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-4532
Practice Address - Country:US
Practice Address - Phone:847-894-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0546881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice