Healthcare Provider Details

I. General information

NPI: 1205430816
Provider Name (Legal Business Name): KIBEOM SEO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MYRTLE ST
NEW BRITAIN CT
06051-1859
US

IV. Provider business mailing address

4234 TOWN BROOKE
MIDDLETOWN CT
06457-6612
US

V. Phone/Fax

Practice location:
  • Phone: 860-801-8650
  • Fax:
Mailing address:
  • Phone: 716-352-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12938
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12938
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: