MEDICARE: HERZOG PRESTON ROYAL PLLC

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	20423	TX

General Provider Information

NPI Number	:	1457649659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERZOG PRESTON ROYAL PLLC

Provider Business Mailing Address
First Line	:	10763 PRESTON RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-3806
Country	:	US
Telephone Number	:	214-217-4411
Fax Number	:

Provider Business Practice Location Address
First Line	:	10763 PRESTON RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-3806
Country	:	US
Telephone Number	:	214-217-4411
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	DR. CLINT HERZOG
Credential	:	DDS
Telephone Number	:	214-208-1666

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/29/2014

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