Provider Demographics
NPI:1922374263
Name:HERZOG SOUTHLAKE PC
Entity Type:Organization
Organization Name:HERZOG SOUTHLAKE PC
Other - Org Name:FLOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:F
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-328-0110
Mailing Address - Street 1:2600 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6634
Mailing Address - Country:US
Mailing Address - Phone:817-328-0110
Mailing Address - Fax:817-328-0121
Practice Address - Street 1:2600 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6634
Practice Address - Country:US
Practice Address - Phone:817-328-0110
Practice Address - Fax:817-328-0121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty