Provider Demographics
NPI:1548565831
Name:SHANK CENTER FOR DENTISTRY LLC
Entity Type:Organization
Organization Name:SHANK CENTER FOR DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-788-4239
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1201391A122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7569010001Medicare NSC