Basic Information
| Provider Information | |||||||||
| NPI: | 1568085264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | CURTIS | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | C213 MEDINN, SPC 5831 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349365950 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | C213 MEDINN, SPC 5831 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349365950 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2020 | ||||||||
| LastUpdateDate: | 04/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901600466 | MI | N | Dental Providers | Dentist | 390200000X | 2901600466 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.