Provider Demographics
NPI:1548702244
Name:HERMITAGE PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:HERMITAGE PEDIATRIC DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-410-1340
Mailing Address - Street 1:1100 NEAL ST STE B
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0900
Mailing Address - Country:US
Mailing Address - Phone:931-349-7807
Mailing Address - Fax:615-316-9197
Practice Address - Street 1:1100 NEAL ST STE B
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0900
Practice Address - Country:US
Practice Address - Phone:931-349-7807
Practice Address - Fax:615-316-9197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERMITAGE PEDIATRIC DENTSITRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-11
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty