Provider Demographics
NPI:1215457767
Name:AFFILIATED DENTAL SPECIALIST PL
Entity type:Organization
Organization Name:AFFILIATED DENTAL SPECIALIST PL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOOPAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:727-522-5599
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:727-526-1702
Practice Address - Street 1:17401 COMMERCE PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3507
Practice Address - Country:US
Practice Address - Phone:813-915-6097
Practice Address - Fax:813-615-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN93191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN9319OtherDENTAL LICENSE