MEDICARE: HERZOG SAN ANTONIO PC

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

General Provider Information

NPI Number	:	1518207802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERZOG SAN ANTONIO PC

Provider Business Mailing Address
First Line	:	19903 STONE OAK PKWY
Second Line	:	BUILDING 1 SUITE 103
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-6953
Country	:	US
Telephone Number	:	210-293-0101
Fax Number	:	210-293-0102

Provider Business Practice Location Address
First Line	:	19903 STONE OAK PKWY
Second Line	:	BUILDING 1 SUITE 103
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-6953
Country	:	US
Telephone Number	:	210-293-0101
Fax Number	:	210-293-0102

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLINTON FINCH HERZOG
Credential	:	DDS
Telephone Number	:	214-218-1666

Provider Enumeration Date	:	02/22/2013
Last Update Date	:	02/22/2013

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Directions to “HERZOG SAN ANTONIO PC ” Practice Location

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