=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073054524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KUKHWA RYU DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2017
-----------------------------------------------------
Last Update Date | 03/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 HARRIS ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95503-4448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-808-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2045 REDWOOD ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95503-8923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-808-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KUKHWA RYU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 714-808-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 55538
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------