Provider Demographics
NPI:1699040121
Name:BRADSHAW, SHENAN MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHENAN
Middle Name:MARIE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 PEACHTREE DUNWOODY RD STE 660
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2018
Mailing Address - Country:US
Mailing Address - Phone:404-220-7505
Mailing Address - Fax:
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD STE 660
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-220-7505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015715204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA80170OtherMEDICAL LICENSE