Provider Demographics
NPI:1255191193
Name:CHANG, JEA HOON (DMD)
Entity type:Individual
Prefix:DR
First Name:JEA
Middle Name:HOON
Last Name:CHANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PALAZZO CIR APT 207
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5809
Mailing Address - Country:US
Mailing Address - Phone:678-672-9679
Mailing Address - Fax:
Practice Address - Street 1:9351 VIKING CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5701
Practice Address - Country:US
Practice Address - Phone:502-554-9336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY11172122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program