Healthcare Provider Details

I. General information

NPI: 1699040121
Provider Name (Legal Business Name): SHENAN MARIE BRADSHAW DDS, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 01/18/2025
Certification Date: 01/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 N OUTER 40 RD STE 103
CHESTERFIELD MO
63005-1364
US

IV. Provider business mailing address

17300 N OUTER 40 RD STE 103
CHESTERFIELD MO
63005-1364
US

V. Phone/Fax

Practice location:
  • Phone: 636-536-5158
  • Fax:
Mailing address:
  • Phone: 636-536-5158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2020029150
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: