Healthcare Provider Details

I. General information

NPI: 1275595290
Provider Name (Legal Business Name): MARK A. HERZOG D.D.S, P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/14/2013
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 Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6296
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: