Healthcare Provider Details

I. General information

NPI: 1568085264
Provider Name (Legal Business Name): CURTIS RICHARD HERZOG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DRIVE C213 MEDINN, SPC 5831
ANN ARBOR MI
48109-5831
US

IV. Provider business mailing address

1500 E MEDICAL CENTER DRIVE C213 MEDINN, SPC 5831
ANN ARBOR MI
48109-5831
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-5950
  • Fax:
Mailing address:
  • Phone: 734-936-5950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901600466
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901600466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: