Provider Demographics
NPI:1740662246
Name:HERZOG, MARK BRADY (DMD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRADY
Last Name:HERZOG
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 1:6911 RAVENS GATE WAY
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-2189
Mailing Address - Country:US
Mailing Address - Phone:509-965-4718
Mailing Address - Fax:
Practice Address - Street 1:6520 226TH PL SE
Practice Address - Street 2:SUITE 200
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8969
Practice Address - Country:US
Practice Address - Phone:425-392-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605665771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice