MEDICARE: AFFILIATED DENTAL SPECIALIST PL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DN9319	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DN9319	OTHER	FL	DENTAL LICENSE

General Provider Information

NPI Number	:	1215457767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFILIATED DENTAL SPECIALIST PL

Provider Business Mailing Address
First Line	:	6311 4TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-7511
Country	:	US
Telephone Number	:	727-522-5599
Fax Number	:	727-526-1702

Provider Business Practice Location Address
First Line	:	17401 COMMERCE PARK BLVD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3507
Country	:	US
Telephone Number	:	813-915-6097
Fax Number	:	813-615-0750

Authorized Official
Title or Position	:	DOCTOR
Name	:	ALAN SHOOPAK
Credential	:	DMD
Telephone Number	:	727-522-5599

Provider Enumeration Date	:	06/26/2017
Last Update Date	:	10/10/2017

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