Provider Demographics
NPI:1104555093
Name:SEO, JOANNA HAEWON (DMD)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:HAEWON
Last Name:SEO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:HAEWON SEO
Other - Last Name:HAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-3156
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:SCHOOL OF DENTISTRY - ADVANCED GENERAL DENTISTRY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-6028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4291-221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice