Healthcare Provider Details

I. General information

NPI: 1801316310
Provider Name (Legal Business Name): AFFILIATED DENTAL SPECIALIST PL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

13129 N DALE MABRY HWY STE H
TAMPA FL
33618-2444
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 813-337-6745
  • Fax: 813-963-3545
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