Provider Demographics
NPI:1124112560
Name:HERZOG, CLINT F (DDS)
Entity type:Individual
Prefix:MR
First Name:CLINT
Middle Name:F
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 1:2828 ROUTH
Mailing Address - Street 2:310
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201
Mailing Address - Country:US
Mailing Address - Phone:214-969-1000
Mailing Address - Fax:
Practice Address - Street 1:2828 ROUTH
Practice Address - Street 2:310
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201
Practice Address - Country:US
Practice Address - Phone:214-969-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice