Provider Demographics
NPI:1790218709
Name:HERZOG, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:398 192ND ARMOR TANK BATTALION RD
Mailing Address - Street 2:BLDG 1022 ROOM 231
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5116
Mailing Address - Country:US
Mailing Address - Phone:502-624-6158
Mailing Address - Fax:
Practice Address - Street 1:398 192ND ARMOR TANK BATTALION RD
Practice Address - Street 2:BLDG 1022 ROOM 231
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5116
Practice Address - Country:US
Practice Address - Phone:502-624-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1820124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist