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General NPI Number Information
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NPI Number | 1144507351
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Entity Type | Organization
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Legal Business Name | CARROLL R. SHANKS, D.D.S., P.C.
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Dates
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Enumeration Date | 11/16/2011
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Last Update Date | 08/29/2012
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Provider Practice Location Address
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Address Line | 1511 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5131
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Country | US
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Telephone | 865-977-8048
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Fax | 865-977-0318
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Provider Business Mailing Address
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Address Line | 1511 E LAMAR ALEXANDER PKWY
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City | MARYVILLE
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State | TN
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Zip | 37804-5131
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Country | US
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Telephone | 865-977-8048
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Fax | 865-977-0318
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Authorized Official
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Title or Position | OWNER
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Name | CARROLL RUDOLPH SHANKS
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Credential | ORAL SURGEON
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Telephone | 865-977-8048
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | TN2381
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | TN2381
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License Number State | TN
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