Provider Demographics
NPI:1508917337
Name:SCHUPACK, ALAN DAVID (DDS)
Entity Type:Individual
Prefix:MR
First Name:ALAN
Middle Name:DAVID
Last Name:SCHUPACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT66751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice