Individual
DR. RAYMOND PATRICK SHUPAK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD, MD
Contact information
Practice address
1500 SOUTH MAIN STREET JPS HOSPITAL, DEPT OF OMFS, FORT WORTH, TX 76104
(817) 702-5595
Mailing address
1500 SOUTH MAIN STREET JPS HOSPITAL, DEPT OF OMFS, FORT WORTH, TX 76104
(817) 702-5595
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
35670
TX
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
DS038719
PA
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
MD461668
PA
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
S4567
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1029564820001
—
PA
Enumeration date
06/22/2011
Last updated
05/24/2021
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