Provider Demographics
NPI:1962798462
Name:SHUPAK, RAYMOND PATRICK (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:PATRICK
Last Name:SHUPAK
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 SOUTH MAIN STREET JPS HOSPITAL
Mailing Address - Street 2:DEPT OF OMFS
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-702-5595
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTH MAIN STREET JPS HOSPITAL
Practice Address - Street 2:DEPT OF OMFS
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-702-5595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0387191223S0112X
TXS4567204E00000X
PAMD461668204E00000X
TX356701223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029564820001Medicaid