Provider Demographics
NPI:1174852958
Name:HERMITAGE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:HERMITAGE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRKLAND
Authorized Official - Middle Name:E
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-889-1654
Mailing Address - Street 1:107 BONNABROOK DR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-1910
Mailing Address - Country:US
Mailing Address - Phone:615-889-1654
Mailing Address - Fax:615-316-9197
Practice Address - Street 1:107 BONNABROOK DR
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-1910
Practice Address - Country:US
Practice Address - Phone:615-889-1654
Practice Address - Fax:615-316-9197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8202261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental