Provider Demographics
NPI:1215586037
Name:SEO, WONKYU (DDS)
Entity Type:Individual
Prefix:
First Name:WONKYU
Middle Name:
Last Name:SEO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 E CRAIG RD STE 102
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3321
Mailing Address - Country:US
Mailing Address - Phone:702-680-1009
Mailing Address - Fax:702-577-3937
Practice Address - Street 1:1820 E CRAIG RD STE 102
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3321
Practice Address - Country:US
Practice Address - Phone:702-680-1009
Practice Address - Fax:702-577-3937
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV72901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice