MEDICARE: DR. HAE RIM RYU DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	30069	TX
2	1223G0001X	General Practice Dentistry	DDS101303	CA

General Provider Information

NPI Number	:	1982018909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAE RIM RYU DMD

Provider Business Mailing Address
First Line	:	3820 CONVOY STREET
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111
Country	:	US
Telephone Number	:	206-832-7702
Fax Number	:

Provider Business Practice Location Address
First Line	:	3820 CONVOY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3722
Country	:	US
Telephone Number	:	206-832-7702
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2014
Last Update Date	:	07/21/2022

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