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 1:325 GAMBRILLS RD STE C
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1102
Mailing Address - Country:US
Mailing Address - Phone:410-923-0373
Mailing Address - Fax:
Practice Address - Street 1:325 GAMBRILLS RD STE C
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1102
Practice Address - Country:US
Practice Address - Phone:410-923-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016.01340231223G0001X
NH047111223G0001X
MD185511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice