Provider Demographics
NPI:1427402981
Name:SEO, SANG KWON
Entity Type:Individual
Prefix:
First Name:SANG KWON
Middle Name:
Last Name:SEO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12989 JUPITER RD STE 106
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-5248
Mailing Address - Country:US
Mailing Address - Phone:214-343-9115
Mailing Address - Fax:
Practice Address - Street 1:12989 JUPITER RD STE 106
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238-5248
Practice Address - Country:US
Practice Address - Phone:214-343-9115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX331381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice