Provider Demographics
NPI:1962837617
Name:KIM, SEO YOUNG
Entity Type:Individual
Prefix:
First Name:SEO YOUNG
Middle Name:
Last Name:KIM
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 1:3728 11TH ST NW
Mailing Address - Street 2:APT A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107
Mailing Address - Country:US
Mailing Address - Phone:818-333-6199
Mailing Address - Fax:
Practice Address - Street 1:5608 ZUNI RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2926
Practice Address - Country:US
Practice Address - Phone:505-262-6547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4649122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist