Healthcare Provider Details

I. General information

NPI: 1104193366
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: 11/16/2011
Last Update Date: 02/10/2012
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 TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberDS7825
License Number StateTN

VIII. Authorized Official

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