Provider Demographics
NPI:1427417807
Name:CHANG, JEFFREY (DMD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1040
Practice Address - Country:US
Practice Address - Phone:650-575-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARR60583726390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program