Provider Demographics
NPI:1497885412
Name:HERMITAGE DENTAL CLINIC
Entity Type:Organization
Organization Name:HERMITAGE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURDESHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-889-1654
Mailing Address - Street 1:107 BONNABROOK DR STE 1
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 STE 1
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:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1764261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental