Individual
CHARLES HARTWELL SHANKS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
1511 E LAMAR ALEXANDER PKWY, MARYVILLE, TN 37804-5131
(865) 977-8048
(865) 977-0318
Mailing address
1511 E LAMAR ALEXANDER PKWY, MARYVILLE, TN 37804-5131
(865) 977-8048
(865) 977-0318
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
DS7825
TN
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
DS7825
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1144507351
GROUP NPI
TN
01
—
1223S0112X
KENTUCKY MEDICAID TAXONOMY CODE
TN
01
—
201169265
TAX ID
TN
01
—
DS7825
LICENSE #
TN
Enumeration date
10/12/2005
Last updated
06/17/2013
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