Healthcare Provider Details

I. General information

NPI: 1063498020
Provider Name (Legal Business Name): GARY HOWARD SHANKER D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12111 TESSON FERRY PROFESSIONAL CTR
SAINT LOUIS MO
63128-1250
US

IV. Provider business mailing address

12111 TESSON FERRY PROFESSIONAL CTR
SAINT LOUIS MO
63128-1250
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-4105
  • Fax: 314-842-3580
Mailing address:
  • Phone: 314-842-4105
  • Fax: 314-842-3580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number000363
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: