Healthcare Provider Details

I. General information

NPI: 1710327614
Provider Name (Legal Business Name): HOJOONG RYU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVID RYU DDS

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 FORT WORTH ST STE 100
GRAND PRAIRIE TX
75050-5404
US

IV. Provider business mailing address

1017 FORT WORTH ST STE 100
GRAND PRAIRIE TX
75050-5404
US

V. Phone/Fax

Practice location:
  • Phone: 469-827-7554
  • Fax:
Mailing address:
  • Phone: 469-827-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE60399986
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3988
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30446
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: