MEDICARE: MR. CLINT F HERZOG D.D.S.

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	1223G0001X	General Practice Dentistry	20239	TX

General Provider Information

NPI Number	:	1124112560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CLINT F HERZOG D.D.S.

Provider Business Mailing Address
First Line	:	2828 ROUTH
Second Line	:	310
City	:	DALLAS
State	:	TX
Zip	:	75201
Country	:	US
Telephone Number	:	214-969-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2828 ROUTH
Second Line	:	310
City	:	DALLAS
State	:	TX
Zip	:	75201
Country	:	US
Telephone Number	:	214-969-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	07/08/2007

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