Healthcare Provider Details

I. General information

NPI: 1386566685
Provider Name (Legal Business Name): KEVIN SEUNG HEO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 JAMES MADISON ROAD
KINGS BAY GA
31547
US

IV. Provider business mailing address

11919 COLERAIN RD APT 1023
SAINT MARYS GA
31558-2910
US

V. Phone/Fax

Practice location:
  • Phone: 912-573-8713
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124197
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: