Healthcare Provider Details

I. General information

NPI: 1760997175
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: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 RINGLING BLVD STE 500
SARASOTA FL
34236-6830
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 727-522-5599
  • Fax:
Mailing address:
  • Phone: 727-522-5599
  • Fax:

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