Provider Demographics
NPI:1205430816
Name:SEO, KIBEOM (DDS)
Entity type:Individual
Prefix:
First Name:KIBEOM
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 1:4234 TOWN BROOKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-6612
Mailing Address - Country:US
Mailing Address - Phone:716-352-8080
Mailing Address - Fax:
Practice Address - Street 1:105 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-1859
Practice Address - Country:US
Practice Address - Phone:860-801-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT129381223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist