Provider Demographics
NPI:1154349439
Name:SHANK, JOHN JACOB (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JACOB
Last Name:SHANK
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 1:2121 E DUPONT RD STE C
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1546
Mailing Address - Country:US
Mailing Address - Phone:260-490-2013
Mailing Address - Fax:260-490-1081
Practice Address - Street 1:2121 E DUPONT RD STE C
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1546
Practice Address - Country:US
Practice Address - Phone:260-490-2013
Practice Address - Fax:260-490-1081
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120095841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000214282OtherBLUE CROSS BLUE SHIELD
190009098OtherRAILROAD MEDICARE
IN200169990AMedicaid
190009098OtherRAILROAD MEDICARE
000000214282OtherBLUE CROSS BLUE SHIELD