Healthcare Provider Details

I. General information

NPI: 1093243651
Provider Name (Legal Business Name): JE DONG RYU DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8680 MONROE CT STE 200
RANCHO CUCAMONGA CA
91730-9104
US

IV. Provider business mailing address

27000 W LUGONIA AVE APT 4103
REDLANDS CA
92374-2081
US

V. Phone/Fax

Practice location:
  • Phone: 909-987-0899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number101782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: