Provider Demographics
NPI:1528335254
Name:CHANG, IRENE (DDS)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
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:PSC 561
Mailing Address - Street 2:BOX 343
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 561 BOX 343
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96310-0004
Practice Address - Country:US
Practice Address - Phone:315-253-6909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14835122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist