Provider Demographics
NPI:1306063631
Name:HERZOG, STEVEN (DDS, MS)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:HERZOG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4113
Mailing Address - Country:US
Mailing Address - Phone:773-761-7171
Mailing Address - Fax:773-761-6714
Practice Address - Street 1:2440 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4113
Practice Address - Country:US
Practice Address - Phone:773-761-7171
Practice Address - Fax:773-761-6714
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0161111223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019016111Medicaid
IL527100Medicare PIN