Provider Demographics
NPI:1003986381
Name:HERZOG, CHRISTOPHER W (DDS)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:W
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 1:1502 E VANETTA LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99217-5515
Mailing Address - Country:US
Mailing Address - Phone:509-290-6031
Mailing Address - Fax:509-755-0444
Practice Address - Street 1:605 E HOLLAND AVE STE 222
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1246
Practice Address - Country:US
Practice Address - Phone:509-755-5437
Practice Address - Fax:509-755-0444
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA104141223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5038211Medicaid
WA5038195Medicaid