Provider Demographics
NPI:1326177551
Name:HEROD, OTTO L (DDS)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:L
Last Name:HEROD
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 1:1621 PAT BOOKER RD
Mailing Address - Street 2:
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3432
Mailing Address - Country:US
Mailing Address - Phone:210-654-9094
Mailing Address - Fax:210-655-9292
Practice Address - Street 1:1621 PAT BOOKER RD
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3432
Practice Address - Country:US
Practice Address - Phone:210-654-9094
Practice Address - Fax:210-655-9292
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice