Healthcare Provider Details

I. General information

NPI: 1114272580
Provider Name (Legal Business Name): CHARLES H. SHANKS, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 E LAMAR ALEXANDER PKWY
MARYVILLE TN
37804-5131
US

IV. Provider business mailing address

1511 E LAMAR ALEXANDER PKWY
MARYVILLE TN
37804-5131
US

V. Phone/Fax

Practice location:
  • Phone: 865-977-8048
  • Fax: 865-977-0318
Mailing address:
  • Phone: 865-977-8048
  • Fax: 865-977-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS7825
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS7825
License Number StateTN

VIII. Authorized Official

Name: CHARLES HARTWELL SHANKS
Title or Position: OWNER/ORAL SURGEON
Credential: D.D.S.
Phone: 865-977-8048