Healthcare Provider Details

I. General information

NPI: 1487992004
Provider Name (Legal Business Name): MARK A.HERZOG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 E 8TH ST
ELLSWORTH KS
67439-2535
US

IV. Provider business mailing address

804 E 8TH ST
ELLSWORTH KS
67439-2535
US

V. Phone/Fax

Practice location:
  • Phone: 785-472-5420
  • Fax: 785-472-8995
Mailing address:
  • Phone: 785-472-5420
  • Fax: 785-472-8995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6269
License Number StateKS

VIII. Authorized Official

Name: DR. MARK ALAN HERZOG
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 785-472-5420