Provider Demographics
NPI:1518587518
Name:HARTZOG, STEPHEN KYLE (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:KYLE
Last Name:HARTZOG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 BELMONT AVE APT 4222
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6893
Mailing Address - Country:US
Mailing Address - Phone:843-327-6145
Mailing Address - Fax:
Practice Address - Street 1:501 S STEMMONS FWY
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-4562
Practice Address - Country:US
Practice Address - Phone:972-436-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX392441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry