Provider Demographics
NPI:1023237708
Name:CHANG, KOOK-JIN (DDS)
Entity type:Individual
Prefix:DR
First Name:KOOK-JIN
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 1:1749 GRAND CONCOURSE
Mailing Address - Street 2:W2K
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-8000
Mailing Address - Country:US
Mailing Address - Phone:928-380-5044
Mailing Address - Fax:
Practice Address - Street 1:234 E. 149TH ST.
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:718-579-5396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA525881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
G9801103OtherHEALTHY FAMILIES DELTA
CAG9151801OtherMEDI CAL