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General NPI Number Information
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NPI Number | 1497885412
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Entity Type | Organization
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Legal Business Name | HERMITAGE DENTAL CLINIC
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 107 BONNABROOK DR STE 1
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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 STE 1
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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 | OWNER
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Name | DR. CHARLES A. BURDESHAW
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Credential | DDS
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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 | 1764
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License Number State | TN
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