Provider Demographics
NPI:1205974458
Name:SHOOPAK, ALAN DAVID (DMD,PA)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:DAVID
Last Name:SHOOPAK
Suffix:
Gender:M
Credentials:DMD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:727-522-5599
Mailing Address - Fax:
Practice Address - Street 1:6311 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-7511
Practice Address - Country:US
Practice Address - Phone:727-522-5599
Practice Address - Fax:727-526-1702
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN151991223X0400X
FLDN93191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110010278AMedicaid
FL075690300Medicaid