Healthcare Provider Details

I. General information

NPI: 1205974458
Provider Name (Legal Business Name): ALAN DAVID SHOOPAK D.M.D.,P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 10/06/2017
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN15199
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN9319
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: