Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 053589 | NY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 247005 | NY |
NPI | 1306969415 |
---|---|
Provider Name | Robert Chang |
First Address | Albany, NY 12205-6433 |
Second Address | Albany, NY 12205-6433 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2007 |
Last Update Date | 21/06/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02926121 | (05) | NY |