Provider Demographics
NPI:1124250543
Name:HERTZOG, CHARLES F (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:F
Last Name:HERTZOG
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 1:118 DICKERSON RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-2538
Mailing Address - Country:US
Mailing Address - Phone:215-699-9058
Mailing Address - Fax:215-699-9599
Practice Address - Street 1:118 DICKERSON RD
Practice Address - Street 2:SUITE D
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-2538
Practice Address - Country:US
Practice Address - Phone:215-699-9058
Practice Address - Fax:215-699-9599
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS024908L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice