Provider Demographics
NPI:1902590821
Name:CHANGA, KIRAN
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:
Last Name:CHANGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 REMINGTON CT
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-6806
Mailing Address - Country:US
Mailing Address - Phone:732-991-7806
Mailing Address - Fax:
Practice Address - Street 1:110 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2495
Practice Address - Country:US
Practice Address - Phone:732-991-7806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRESIDENT122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist