Provider Demographics
NPI:1477067221
Name:SEO, DAL S (LAC)
Entity Type:Individual
Prefix:
First Name:DAL
Middle Name:S
Last Name:SEO
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 S EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2611
Mailing Address - Country:US
Mailing Address - Phone:714-213-8426
Mailing Address - Fax:
Practice Address - Street 1:715 S EUCLID ST
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2611
Practice Address - Country:US
Practice Address - Phone:714-213-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC15525171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC15525OtherACUPUNCTURE