=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669884268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AARON SHOOPAK D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2014
-----------------------------------------------------
Last Update Date | 06/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6311 4TH ST N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33702-7511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-522-5599
-----------------------------------------------------
Fax | 727-526-1702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6311 4TH ST N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33702-7511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-522-5599
-----------------------------------------------------
Fax | 727-526-1702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | DN21759
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------