Provider Demographics
NPI:1407335961
Name:SECD HERMITAGE LLC
Entity Type:Organization
Organization Name:SECD HERMITAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:205-915-1865
Mailing Address - Street 1:1040 NATCHEZ VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-4704
Mailing Address - Country:US
Mailing Address - Phone:205-915-1865
Mailing Address - Fax:
Practice Address - Street 1:260 JACKSON MEADOWS DR
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-1425
Practice Address - Country:US
Practice Address - Phone:205-915-1865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental