Provider Demographics
NPI:1871625137
Name:SHUPACK, BRET E (DDS)
Entity type:Individual
Prefix:
First Name:BRET
Middle Name:E
Last Name:SHUPACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 HARBOR AVE SW
Mailing Address - Street 2:STE 100
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116
Mailing Address - Country:US
Mailing Address - Phone:206-933-9300
Mailing Address - Fax:206-933-9301
Practice Address - Street 1:1331 HARBOR AVE SW
Practice Address - Street 2:STE 100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116
Practice Address - Country:US
Practice Address - Phone:206-933-9300
Practice Address - Fax:206-933-9301
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007765122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2684014OtherUT ACCT #
FL2684014OtherUT ACCT #