Provider Demographics
NPI:1205212388
Name:HERZOG, KATHLEEN (RDH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:CHIRDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-0568
Mailing Address - Country:US
Mailing Address - Phone:503-352-8657
Mailing Address - Fax:503-352-8658
Practice Address - Street 1:9000 SW DURHAM RD
Practice Address - Street 2:BUILDING 710
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-5539
Practice Address - Country:US
Practice Address - Phone:503-359-4057
Practice Address - Fax:503-359-4756
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH5492124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist