Provider Demographics
NPI:1285668418
Name:HERROLD, GEORGE WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WARREN
Last Name:HERROLD
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 1:1650 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104
Mailing Address - Country:US
Mailing Address - Phone:717-230-3957
Mailing Address - Fax:717-231-5761
Practice Address - Street 1:5100 BOARD RD
Practice Address - Street 2:
Practice Address - City:MOUNT WOLF
Practice Address - State:PA
Practice Address - Zip Code:17347-9559
Practice Address - Country:US
Practice Address - Phone:717-266-6694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020745L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005835100002Medicaid