Provider Demographics
NPI:1861468191
Name:SHACKLE, KENNETH L (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:SHACKLE
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 1:25 CHICKADEE RD
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-1806
Mailing Address - Country:US
Mailing Address - Phone:843-681-4142
Mailing Address - Fax:
Practice Address - Street 1:230 DUNCAN DR
Practice Address - Street 2:BLDG. 1440 - HAAF
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31409-5107
Practice Address - Country:US
Practice Address - Phone:912-315-5417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice