Basic Information
| Provider Information | |||||||||
| NPI: | 1265616338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 72724 TWENTYNINE PALMS HWY | ||||||||
| Address2: | SUITE #102 | ||||||||
| City: | TWENTYNINE PALMS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922771461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603676755 | ||||||||
| FaxNumber: | 7603675016 | ||||||||
| Practice Location | |||||||||
| Address1: | 5TH & WESTERN | ||||||||
| Address2: | CALIFORNIA REHABILITATION CENTER | ||||||||
| City: | NORCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
| FaxNumber: | 9512732326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2007 | ||||||||
| LastUpdateDate: | 12/24/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 35900 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.