Provider Demographics
NPI:1801013933
Name:RYU, KUKHWA
Entity Type:Individual
Prefix:DR
First Name:KUKHWA
Middle Name:
Last Name:RYU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2324
Mailing Address - Country:US
Mailing Address - Phone:661-397-7400
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:4401 MING AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-4817
Practice Address - Country:US
Practice Address - Phone:661-397-7400
Practice Address - Fax:661-397-5639
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55538122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55538Medicaid