MEDICARE: AFILLIATED 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	122300000X	Dentist	DN9319	FL

General Provider Information

NPI Number	:	1457800864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFILLIATED 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	:	16010 NW 57TH AVE STE 106&108
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-6706
Country	:	US
Telephone Number	:	786-319-9058
Fax Number	:	305-231-2020

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	ALAN D SHOOPAK
Credential	:	DMD
Telephone Number	:	786-319-9058

Provider Enumeration Date	:	09/27/2016
Last Update Date	:	10/09/2017

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