Healthcare Provider Details

I. General information

NPI: 1013280189
Provider Name (Legal Business Name): MRUDULA CHAMAKURA REPAKA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2012
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 EAGLE ST APT D
SAN DIEGO CA
92103-3960
US

IV. Provider business mailing address

3660 EAGLE ST APT D
SAN DIEGO CA
92103-3960
US

V. Phone/Fax

Practice location:
  • Phone: 619-384-0743
  • Fax:
Mailing address:
  • Phone: 619-384-0743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: