Provider Demographics
NPI:1518047679
Name:HANDLEY, CHARLEY SHANE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLEY
Middle Name:SHANE
Last Name:HANDLEY
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 1:318 MID RIVERS MALL DR
Mailing Address - Street 2:UNIT J
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:318 MID RIVERS MALL DR
Practice Address - Street 2:UNIT J
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1575
Practice Address - Country:US
Practice Address - Phone:636-970-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004025275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist