Provider Demographics
NPI:1881906360
Name:SHANKS, JOHN VAN BRADLEY (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:VAN BRADLEY
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 1:3086 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37367
Mailing Address - Country:US
Mailing Address - Phone:423-447-2421
Mailing Address - Fax:423-447-3408
Practice Address - Street 1:3086 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37367
Practice Address - Country:US
Practice Address - Phone:423-447-2421
Practice Address - Fax:423-447-3408
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN91281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice