# MARK A.HERZOG

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1487992004
- **Authorized official:** DR. MARK ALAN HERZOG D.D.S. (PRESIDENT)
- **Authorized official phone:** (785) 472-5420

## Contact information

- **Practice address:** 804 E 8TH ST, ELLSWORTH, KS 67439-2535
- **Practice address phone:** (785) 472-5420
- **Practice address fax:** (785) 472-8995
- **Mailing address:** 804 E 8TH ST, ELLSWORTH, KS 67439-2535
- **Mailing address phone:** (785) 472-5420
- **Mailing address fax:** (785) 472-8995

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 6269 | KS | Yes |

## Other

- **Enumeration date:** 01/17/2013
- **Last updated:** 01/17/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100223300B | — | KS |