Healthcare Provider Details

I. General information

NPI: 1669884268
Provider Name (Legal Business Name): AARON SHOOPAK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2014
Last Update Date: 06/21/2016
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 Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN21759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: