Provider Demographics
NPI:1902442767
Name:CHANG, EDWARD JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
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 1:99 JOHN ST APT 222
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-2902
Mailing Address - Country:US
Mailing Address - Phone:516-779-0014
Mailing Address - Fax:
Practice Address - Street 1:3907 PRINCE ST STE 5E
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5308
Practice Address - Country:US
Practice Address - Phone:718-461-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI002744400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist