Provider Demographics
NPI:1356492185
Name:ALAN D SCHUPACK DDS LLC
Entity Type:Organization
Organization Name:ALAN D SCHUPACK DDS LLC
Other - Org Name:ALAN D SCHUPACK DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SCHUPACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-294-4444
Mailing Address - Street 1:850 NO MAIN STREET EXTENSION
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-269-4249
Mailing Address - Fax:203-294-4444
Practice Address - Street 1:850 NO MAIN STREET EXTENSION
Practice Address - Street 2:SUITE 2B
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-269-4249
Practice Address - Fax:203-294-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT66751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty