Provider Demographics
NPI:1356500102
Name:SHANK, KYLE W (DDS)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:W
Last Name:SHANK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6904 S EAST ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2693
Mailing Address - Country:US
Mailing Address - Phone:317-788-4239
Mailing Address - Fax:
Practice Address - Street 1:6904 S EAST ST
Practice Address - Street 2:SUITE F
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2693
Practice Address - Country:US
Practice Address - Phone:317-788-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011391A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist