Healthcare Provider Details

I. General information

NPI: 1407145717
Provider Name (Legal Business Name): ALAN D SHOOPAK DMD ORTHODONTIC GROUP VI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 N JOHN YOUNG PKWY
KISSIMMEE FL
34741-4210
US

IV. Provider business mailing address

6311 4TH ST N
ST PETERSBURG FL
33702-7511
US

V. Phone/Fax

Practice location:
  • Phone: 407-483-5797
  • Fax: 407-483-5799
Mailing address:
  • Phone: 727-522-5599
  • Fax: 727-526-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN9319
License Number StateFL

VIII. Authorized Official

Name: DR. ALAN DAVID SHOOPAK
Title or Position: OWNER
Credential: DMD
Phone: 727-522-5599