Provider Demographics
NPI:1558359695
Name:SHANKS, CHARLES HARTWELL (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:HARTWELL
Last Name:SHANKS
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 1:1511 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
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS7825122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1223S0112XOtherKENTUCKY MEDICAID TAXONOMY CODE
TN201169265OtherTAX ID
TNDS7825OtherLICENSE #
TN1144507351OtherGROUP NPI
TN1144507351OtherGROUP NPI