Provider Demographics
NPI:1144507351
Name:CARROLL R. SHANKS, D.D.S., P.C.
Entity type:Organization
Organization Name:CARROLL R. SHANKS, D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARROLL
Authorized Official - Middle Name:RUDOLPH
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?:Yes
Parent Organization LBN:CARROLL R. SHANKS, D.D.S., P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-16
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN2381122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT74217Medicare UPIN