Healthcare Provider Details

I. General information

NPI: 1003477399
Provider Name (Legal Business Name): ANDREW HOSEUNG RYU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 NW 107TH AVE 3RD FLOOR
DORAL FL
33178
US

IV. Provider business mailing address

3601 NW 107TH AVE 3RD FLOOR
DORAL FL
33178
US

V. Phone/Fax

Practice location:
  • Phone: 305-418-7771
  • Fax:
Mailing address:
  • Phone: 305-418-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35349
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number35349
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: