Provider Demographics
NPI:1578858163
Name:HERZOG LEGACY PC
Entity Type:Organization
Organization Name:HERZOG LEGACY PC
Other - Org Name:FLOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-871-7100
Mailing Address - Street 1:5800 LEGACY DR STE C8
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-7101
Mailing Address - Country:US
Mailing Address - Phone:469-368-0101
Mailing Address - Fax:469-368-0102
Practice Address - Street 1:5800 LEGACY DR STE C8
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-7101
Practice Address - Country:US
Practice Address - Phone:469-368-0101
Practice Address - Fax:469-368-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20239122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty