1174658165 NPI number — ALAN D SHOOPAK DMD ORTHODONTIC GROUP IV LLC

Table of content: (NPI 1174658165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174658165 NPI number — ALAN D SHOOPAK DMD ORTHODONTIC GROUP IV LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALAN D SHOOPAK DMD ORTHODONTIC GROUP IV LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174658165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6311 4TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33702-7511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-522-5599
Provider Business Mailing Address Fax Number:
727-526-1702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 SEBASTIAN BLVD
Provider Second Line Business Practice Location Address:
STE. B
Provider Business Practice Location Address City Name:
SEBASTIAN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32958-4379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-388-5666
Provider Business Practice Location Address Fax Number:
772-388-2038
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHOOPAK
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
727-522-5599

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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