Provider Demographics
NPI:1982018909
Name:RYU, HAE RIM (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAE RIM
Middle Name:
Last Name:RYU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 CONVOY STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111
Mailing Address - Country:US
Mailing Address - Phone:206-832-7702
Mailing Address - Fax:
Practice Address - Street 1:3820 CONVOY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3722
Practice Address - Country:US
Practice Address - Phone:206-832-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX300691223G0001X
CADDS1013031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice