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General NPI Number Information
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NPI Number | 1174852958
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Entity Type | Organization
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Legal Business Name | HERMITAGE PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 12/08/2009
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Last Update Date | 12/08/2009
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Provider Practice Location Address
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Address Line | 107 BONNABROOK DR
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City | HERMITAGE
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State | TN
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Zip | 37076-1910
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Country | US
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Telephone | 615-889-1654
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Fax | 615-316-9197
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Provider Business Mailing Address
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Address Line | 107 BONNABROOK DR
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City | HERMITAGE
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State | TN
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Zip | 37076-1910
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Country | US
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Telephone | 615-889-1654
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Fax | 615-316-9197
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Authorized Official
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Title or Position | DENTIST
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Name | DR. KIRKLAND E LARSON
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Credential | D.D.S
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Telephone | 615-889-1654
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 8202
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License Number State | TN
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