Mark A. Herzog, D.D.S, P.A.
Individual provider Active NPI General Practice Dentistry · Ellsworth, KS
NPI 1275595290 · NPPES record last updated Jan 14, 2013
Key facts
- NPI
- 1275595290
- Entity type
- Individual (NPI type 1)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- 6296 (KS)
- Practice address
- 804 E 8TH St
Ellsworth, KS 67439-2535 - Phone
- (785) 472-5420
- Fax
- (785) 472-8995
- NPI assigned
- Apr 5, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6296 | KS | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mark a.Herzog | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 6296 | KS | Yes |
Addresses
Primary practice location
804 E 8TH St
Ellsworth, KS 67439-2535
Mailing address
804 E 8TH St
Ellsworth, KS 67439-2535
Phone (785) 472-5420
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100223300B | Medicaid | KS |
Other providers in Ellsworth, KS
- G Derril Gwinner OD LLC
- Grant Derril Gwinner
- Grant K Gwinner
- Christena Hanson
- Mackenzie Leigh Helman
- Ashley Marie Hlad
- Sheri Jonsson
- Savannah Dawn Kelley
- Dennis Joseph Kepka
- Kyle Gwinner OD LLC
All providers in Ellsworth, KS · General Practice Dentistry in Kansas
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 14, 2013. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.