MEDICARE: ALAN D SHOOPAK DMD ORTHODONTIC GROUP VI LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1548599558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALAN D SHOOPAK DMD ORTHODONTIC GROUP VI LLC

Provider Business Mailing Address
First Line	:	6311 4TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-7511
Country	:	US
Telephone Number	:	727-522-5599
Fax Number	:	727-526-1702

Provider Business Practice Location Address
First Line	:	3221 S CONWAY RD STE D
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32812-7354
Country	:	US
Telephone Number	:	407-275-5500
Fax Number	:	407-275-5502

Authorized Official
Title or Position	:	OWNER
Name	:	ALAN D. SHOOPAK
Credential	:	D.M.D.
Telephone Number	:	727-522-5599

Provider Enumeration Date	:	12/22/2009
Last Update Date	:	10/16/2015

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