Provider Demographics
NPI:1588771505
Name:CHANG, PHILIP MINSUK (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:MINSUK
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:MIN
Other - Middle Name:SUK
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1611 CRENSHAW BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-7124
Mailing Address - Country:US
Mailing Address - Phone:424-731-7096
Mailing Address - Fax:424-731-7042
Practice Address - Street 1:1611 CRENSHAW BLVD STE C
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-7124
Practice Address - Country:US
Practice Address - Phone:424-731-7096
Practice Address - Fax:424-731-7042
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist