Provider Demographics
NPI:1497801468
Name:HERZOG, JOHN ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:HERZOG
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 1:78 MCKAY ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915
Mailing Address - Country:US
Mailing Address - Phone:978-922-4427
Mailing Address - Fax:978-927-4937
Practice Address - Street 1:78 MCKAY ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915
Practice Address - Country:US
Practice Address - Phone:978-922-4427
Practice Address - Fax:978-927-4937
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA157901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY51193OtherMASSHEALTH
MA451193OtherBLUE CROSS BLUE SHIELD