Provider Demographics
NPI:1528638384
Name:RU, JAE IL (DMD)
Entity type:Individual
Prefix:DR
First Name:JAE IL
Middle Name:
Last Name:RU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 TOWN WEST RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03264-3428
Mailing Address - Country:US
Mailing Address - Phone:603-728-4379
Mailing Address - Fax:
Practice Address - Street 1:13 TOWN WEST RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-3428
Practice Address - Country:US
Practice Address - Phone:603-728-4379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.01340231223G0001X
NH047111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice