MEDICARE: ALAN D SHOOPAK DMD ORTHODONTIC GROUP IV LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry		FL

General Provider Information

NPI Number	:	1417082405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALAN D SHOOPAK DMD ORTHODONTIC GROUP IV LLC

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	:	1956 41ST AVE
Second Line	:	STE A
City	:	VERO BEACH
State	:	FL
Zip	:	32960-0575
Country	:	US
Telephone Number	:	772-562-2439
Fax Number	:	772-562-9300

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ALAN D. SHOOPAK
Credential	:
Telephone Number	:	727-522-5599

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	02/09/2016

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