Provider Demographics
NPI:1699263186
Name:CHANG, GARY (DMD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1615 WHEELER ST UNIT E
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-4989
Mailing Address - Country:US
Mailing Address - Phone:361-648-5826
Mailing Address - Fax:
Practice Address - Street 1:6715 BISSONNET ST # 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-6129
Practice Address - Country:US
Practice Address - Phone:832-932-9673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34562122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program