MEDICARE: CHARLES HARTWELL SHANKS D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS7825	TN
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DS7825	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	201169265	OTHER	TN	TAX ID
3	DS7825	OTHER	TN	LICENSE #
4	1144507351	OTHER	TN	GROUP NPI

General Provider Information

NPI Number	:	1558359695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES HARTWELL SHANKS D.D.S.

Provider Business Mailing Address
First Line	:	1511 E LAMAR ALEXANDER PKWY
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37804-5131
Country	:	US
Telephone Number	:	865-977-8048
Fax Number	:	865-977-0318

Provider Business Practice Location Address
First Line	:	1511 E LAMAR ALEXANDER PKWY
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37804-5131
Country	:	US
Telephone Number	:	865-977-8048
Fax Number	:	865-977-0318

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	06/17/2013

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Directions to “ CHARLES HARTWELL SHANKS D.D.S.” Practice Location

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