Healthcare Provider Details

I. General information

NPI: 1306077615
Provider Name (Legal Business Name): KYUNG WON SEO D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 COLUMBIA RD
DORCHESTER MA
02125-1712
US

IV. Provider business mailing address

653 COLUMBIA RD
DORCHESTER MA
02125
US

V. Phone/Fax

Practice location:
  • Phone: 617-776-7576
  • Fax: 617-825-5006
Mailing address:
  • Phone: 617-776-7576
  • Fax: 617-825-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1855174
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: