Healthcare Provider Details

I. General information

NPI: 1093978827
Provider Name (Legal Business Name): JASON MARC KOPAKIN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8475 SEMINOLE BLVD
SEMINOLE FL
33772-4329
US

IV. Provider business mailing address

410 S ALBANY AVE APT 4
TAMPA FL
33606-4315
US

V. Phone/Fax

Practice location:
  • Phone: 727-393-6024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN18457
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: