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General NPI Number Information
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NPI Number | 1548565831
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Entity Type | Organization
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Legal Business Name | SHANK CENTER FOR DENTISTRY LLC
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Dates
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Enumeration Date | 01/18/2011
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Last Update Date | 01/30/2017
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Provider Practice Location Address
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Address Line | 6904 S EAST ST SUITE F
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-2693
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Country | US
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Telephone | 317-788-4239
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Fax |
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Provider Business Mailing Address
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Address Line | 6904 S EAST ST SUITE F
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-2693
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Country | US
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Telephone | 317-788-4239
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. KYLE WESLEY SHANK
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Credential | D.D.S.
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Telephone | 317-788-4239
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1201391A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1201391A
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License Number State | IN
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