Healthcare Provider Details

I. General information

NPI: 1548565831
Provider Name (Legal Business Name): SHANK CENTER FOR DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6904 S EAST ST SUITE F
INDIANAPOLIS IN
46227-2693
US

IV. Provider business mailing address

6904 S EAST ST SUITE F
INDIANAPOLIS IN
46227-2693
US

V. Phone/Fax

Practice location:
  • Phone: 317-788-4239
  • Fax:
Mailing address:
  • Phone: 317-788-4239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1201391A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1201391A
License Number StateIN

VIII. Authorized Official

Name: DR. KYLE WESLEY SHANK
Title or Position: SOLE MEMBER
Credential: D.D.S.
Phone: 317-788-4239