Provider Demographics
NPI:1093978827
Name:KOPAKIN, JASON MARC (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MARC
Last Name:KOPAKIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S ALBANY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-4315
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8475 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-4329
Practice Address - Country:US
Practice Address - Phone:727-393-6024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist