MEDICARE: AFFILIATED DENTAL SPECIALIST

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

General Provider Information

NPI Number	:	1497106033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFILIATED DENTAL SPECIALIST

Provider Business Mailing Address
First Line	:	6311 4TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33702-7511
Country	:	US
Telephone Number	:	727-474-0317
Fax Number	:	727-526-1702

Provider Business Practice Location Address
First Line	:	2488 W BRANDON BLVD STE B
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-4710
Country	:	US
Telephone Number	:	813-337-6746
Fax Number	:	813-661-6240

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	ALAN SHOOPAK
Credential	:	DMD
Telephone Number	:	813-337-6746

Provider Enumeration Date	:	06/24/2016
Last Update Date	:	10/09/2017

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