Healthcare Provider Details

I. General information

NPI: 1063965119
Provider Name (Legal Business Name): AFFILIATED DENTAL SPECIALIST PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6311 4TH ST N
ST PETERSBURG FL
33702-7511
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: 727-526-1702
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 Number
License Number State

VIII. Authorized Official

Name: ALAN SHOOPAK
Title or Position: ORTHODONTIST
Credential: DMD
Phone: 727-474-0317