Provider Demographics
NPI:1073731998
Name:HERZBERG, MARK CARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CARL
Last Name:HERZBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 YORK AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1164
Mailing Address - Country:US
Mailing Address - Phone:612-929-7540
Mailing Address - Fax:612-626-2651
Practice Address - Street 1:VA MEDICAL CENTER
Practice Address - Street 2:ONE VETERANS DRIVE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-467-4716
Practice Address - Fax:612-626-2651
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN86871223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics