Healthcare Provider Details

I. General information

NPI: 1003665134
Provider Name (Legal Business Name): ALAN REPAK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 SHINGLE CREEK XING
BROOKLYN CENTER MN
55430-2684
US

IV. Provider business mailing address

2428 DELAWARE ST SE APT 409
MINNEAPOLIS MN
55414-3829
US

V. Phone/Fax

Practice location:
  • Phone: 651-583-7256
  • Fax:
Mailing address:
  • Phone: 701-388-1396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD15109
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: