Provider Demographics
NPI:1134254428
Name:BAEK, SEUNGHO ROBIN (DDS)
Entity type:Individual
Prefix:MR
First Name:SEUNGHO
Middle Name:ROBIN
Last Name:BAEK
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 1:5105 MADISON AVE
Mailing Address - Street 2:C4
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5124
Mailing Address - Country:US
Mailing Address - Phone:517-775-5636
Mailing Address - Fax:
Practice Address - Street 1:1808 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1897
Practice Address - Country:US
Practice Address - Phone:517-372-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI19076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist