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General NPI Number Information
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NPI Number | 1639682669
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Entity Type | Organization
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Legal Business Name | SHANKS DENTISTRY
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Dates
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Enumeration Date | 11/13/2017
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Last Update Date | 11/13/2017
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Provider Practice Location Address
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Address Line | 904 W BROADWAY AVE
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City | MARYVILLE
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State | TN
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Zip | 37801-4637
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Country | US
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Telephone | 865-233-7640
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Fax | 865-233-7660
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Provider Business Mailing Address
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Address Line | 904 WEST BROADWAY AVE
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City | MARYVILLE
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State | TN
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Zip | 37801
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Country | US
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Telephone | 865-233-7640
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Fax | 865-233-7660
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Authorized Official
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Title or Position | OWNER
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Name | TOMMY SPEARS
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Credential | DDS
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Telephone | 865-982-1700
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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 | 4735
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License Number State | TN
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