Healthcare Provider Details

I. General information

NPI: 1265926075
Provider Name (Legal Business Name): BRIAN RYU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 12/01/2024
Certification Date: 12/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 MAIN STREET 702
KATY TX
77494
US

IV. Provider business mailing address

1325 MAIN STREET 702
KATY TX
77494
US

V. Phone/Fax

Practice location:
  • Phone: 281-394-3986
  • Fax:
Mailing address:
  • Phone: 281-394-3986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number38056
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12012959A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: