Provider Demographics
NPI:1104193366
Name:CHARLES H. SHANKS, D.D.S., P.C.
Entity Type:Organization
Organization Name:CHARLES H. SHANKS, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HARTWELL
Authorized Official - Last Name:SHANKS
Authorized Official - Suffix:
Authorized Official - Credentials:ORAL SURGEON
Authorized Official - Phone:865-977-8048
Mailing Address - Street 1:1511 E LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5131
Mailing Address - Country:US
Mailing Address - Phone:865-977-8048
Mailing Address - Fax:865-977-0318
Practice Address - Street 1:1511 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5131
Practice Address - Country:US
Practice Address - Phone:865-977-8048
Practice Address - Fax:865-977-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS7825305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNV00974Medicare UPIN