Basic Information
| Provider Information | |||||||||
| NPI: | 1457337982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | BYUNG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1503 DODONA TER | ||||||||
| Address2: | 105 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201754717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553737688 | ||||||||
| FaxNumber: | 7037719877 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 DODONA TER STE 105 | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201754723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553737688 | ||||||||
| FaxNumber: | 2023972104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2005 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 6025 | LA | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 13440 | MD | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | 0438000313 | VA | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223S0112X | DEN1001258 | DC | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1457337982 | 05 | MD | MEDICAID |