MEDICARE: TATIANA SANTIAGO HERZOG DDS PA

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	DN18993	FL

General Provider Information

NPI Number	:	1629315809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TATIANA SANTIAGO HERZOG DDS PA

Provider Business Mailing Address
First Line	:	3343 NE 33RD ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-7109
Country	:	US
Telephone Number	:	954-563-1362
Fax Number	:

Provider Business Practice Location Address
First Line	:	3343 NE 33RD ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-7109
Country	:	US
Telephone Number	:	954-563-1362
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TATIANA HERZOG
Credential	:	DDS
Telephone Number	:	305-409-5392

Provider Enumeration Date	:	01/08/2013
Last Update Date	:	01/08/2013

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