Healthcare Provider Details

I. General information

NPI: 1972439727
Provider Name (Legal Business Name): JAEKUN RYU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6948 MAGNOLIA AVE
RIVERSIDE CA
92506-2845
US

IV. Provider business mailing address

11651 POPLAR ST
LOMA LINDA CA
92354-3544
US

V. Phone/Fax

Practice location:
  • Phone: 951-263-7649
  • Fax:
Mailing address:
  • Phone: 951-470-6882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113073
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: