Healthcare Provider Details

I. General information

NPI: 1376831206
Provider Name (Legal Business Name): CHANG WOO RYU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 MANOR RD # 103
AUSTIN TX
78723
US

IV. Provider business mailing address

3607 MANOR RD # 103
AUSTIN TX
78723-5812
US

V. Phone/Fax

Practice location:
  • Phone: 512-494-6767
  • Fax:
Mailing address:
  • Phone: 512-494-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number29762
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: