Healthcare Provider Details

I. General information

NPI: 1023813888
Provider Name (Legal Business Name): SHENAN BRADSHAW DDS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

858 BRAWLEY SCHOOL RD STE C
MOORESVILLE NC
28117-8208
US

IV. Provider business mailing address

858 BRAWLEY SCHOOL RD STE C
MOORESVILLE NC
28117-8208
US

V. Phone/Fax

Practice location:
  • Phone: 704-799-3555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER GRAVES
Title or Position: PRACTICE ADMIN
Credential:
Phone: 704-799-3555