Provider Demographics
NPI:1013280189
Name:REPAKA, MRUDULA CHAMAKURA (DDS)
Entity Type:Individual
Prefix:
First Name:MRUDULA
Middle Name:CHAMAKURA
Last Name:REPAKA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 EAGLE ST
Mailing Address - Street 2:APT D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3960
Mailing Address - Country:US
Mailing Address - Phone:619-384-0743
Mailing Address - Fax:
Practice Address - Street 1:3660 EAGLE ST
Practice Address - Street 2:APT D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3960
Practice Address - Country:US
Practice Address - Phone:619-384-0743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA610921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice