Provider Demographics
NPI:1902059348
Name:CHANG, RICARDO (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9646 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6241
Mailing Address - Country:US
Mailing Address - Phone:954-210-7994
Mailing Address - Fax:954-210-7993
Practice Address - Street 1:9646 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6241
Practice Address - Country:US
Practice Address - Phone:954-210-7994
Practice Address - Fax:954-210-7993
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16950122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016623600Medicaid