1316497522 NPI number — AFILLIATED DENTAL SPECIALIST PL

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316497522 NPI number — AFILLIATED DENTAL SPECIALIST PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AFILLIATED DENTAL SPECIALIST PL
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:
1316497522
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2017
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:
2740 SW 97TH AVE APT 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33165-2682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-732-3916
Provider Business Practice Location Address Fax Number:
305-485-4455
Provider Enumeration Date:
10/12/2016

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN9319 , 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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