MEDICARE: HERZOG LAKEWOOD 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	:	1619217908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERZOG LAKEWOOD PC

Provider Business Mailing Address
First Line	:	1920 ABRAMS PKWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-6218
Country	:	US
Telephone Number	:	214-389-0100
Fax Number	:	214-389-0101

Provider Business Practice Location Address
First Line	:	1920 ABRAMS PKWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-6218
Country	:	US
Telephone Number	:	214-389-0100
Fax Number	:	214-389-0101

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLINTON FINCH HERZOG
Credential	:	DDS
Telephone Number	:	214-389-0100

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

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