Provider Demographics
NPI:1275595290
Name:HERZOG, MARK A (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:HERZOG
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:67439-2535
Mailing Address - Country:US
Mailing Address - Phone:785-472-5420
Mailing Address - Fax:785-472-8995
Practice Address - Street 1:804 E 8TH ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:KS
Practice Address - Zip Code:67439-2535
Practice Address - Country:US
Practice Address - Phone:785-472-5420
Practice Address - Fax:785-472-8995
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS62961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100223300BMedicaid