Provider Demographics
NPI:1972891687
Name:SHANK ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:SHANK ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:SHANK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:317-888-9833
Mailing Address - Street 1:1700 W SMITH VALLEY RD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1599
Mailing Address - Country:US
Mailing Address - Phone:317-888-9833
Mailing Address - Fax:317-885-1754
Practice Address - Street 1:1700 W SMITH VALLEY RD
Practice Address - Street 2:SUITE A-1
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1599
Practice Address - Country:US
Practice Address - Phone:317-888-9833
Practice Address - Fax:317-885-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011699A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental