Healthcare Provider Details

I. General information

NPI: 1629598131
Provider Name (Legal Business Name): AFILLIATED DENTAL SPECIALIST PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12920 CORTEZ BLVD
SPRING HILL FL
34613-6803
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 352-835-0330
  • Fax: 352-683-1925
Mailing address:
  • Phone: 727-522-5599
  • Fax: 727-526-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN9319
License Number StateFL

VIII. Authorized Official

Name: ALAN SHOOPAK
Title or Position: DOCTOR
Credential: DMD
Phone: 727-522-5599