Provider Demographics
NPI:1164445284
Name:HERZFELDT, RICHARD ROLAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ROLAND
Last Name:HERZFELDT
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 1:1825 AVENUE OF THE CITIES
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-4859
Mailing Address - Country:US
Mailing Address - Phone:309-797-5789
Mailing Address - Fax:309-797-6441
Practice Address - Street 1:1825 AVENUE OF THE CITIES
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-4859
Practice Address - Country:US
Practice Address - Phone:309-797-5789
Practice Address - Fax:309-797-6441
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A-152801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice