MEDICARE: DR. CHARLES M REPA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	12889	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	12889	TX

General Provider Information

NPI Number	:	1629074547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES M REPA DDS

Provider Business Mailing Address
First Line	:	4185 TECHNOLOGY FOREST BLVD
Second Line	:	SUITE 120
City	:	THE WOODLANDS
State	:	TX
Zip	:	77381-2006
Country	:	US
Telephone Number	:	281-296-9562
Fax Number	:	281-296-9774

Provider Business Practice Location Address
First Line	:	10333 KUYKENDAHL
Second Line	:	SUITE A
City	:	THE WOODLANDS
State	:	TX
Zip	:	77382
Country	:	US
Telephone Number	:	281-296-9562
Fax Number	:	281-296-9774

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	12/18/2015

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