Provider Demographics
NPI:1689289621
Name:ALAN D SHOOPAK DMD ORTHODONTIC GROUP II LLC
Entity Type:Organization
Organization Name:ALAN D SHOOPAK DMD ORTHODONTIC GROUP II LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHOOPAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-561-7666
Mailing Address - Street 1:6311 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-7511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2161 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3810
Practice Address - Country:US
Practice Address - Phone:954-751-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty