MEDICARE: JUNG W SEO DDS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	49990	CA

General Provider Information

NPI Number	:	1811397664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUNG W SEO DDS, INC

Provider Business Mailing Address
First Line	:	531 W LAS TUNAS DR
Second Line	:	SUITE A
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-1166
Country	:	US
Telephone Number	:	626-282-0884
Fax Number	:	626-282-1884

Provider Business Practice Location Address
First Line	:	531 W LAS TUNAS DR
Second Line	:	SUITE A
City	:	SAN GABRIEL
State	:	CA
Zip	:	91776-1166
Country	:	US
Telephone Number	:	626-282-0884
Fax Number	:	626-282-1884

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JUNGWOO SEO
Credential	:	DDS
Telephone Number	:	949-351-6852

Provider Enumeration Date	:	08/29/2014
Last Update Date	:	08/29/2014

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