Healthcare Provider Details

I. General information

NPI: 1790810935
Provider Name (Legal Business Name): ALAN D. SHOOPAK D.M.D. ,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TAMIAMI TRL STE. 110
PORT CHARLOTTE FL
33948-2180
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 941-624-5882
  • Fax: 941-624-5818
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 Number
License Number StateFL

VIII. Authorized Official

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