Provider Demographics
NPI:1144775578
Name:RAJAGOPALAN, NIVEDITHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NIVEDITHA
Middle Name:
Last Name:RAJAGOPALAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 IL-50
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914
Mailing Address - Country:US
Mailing Address - Phone:815-348-9281
Mailing Address - Fax:
Practice Address - Street 1:1501 IL-50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914
Practice Address - Country:US
Practice Address - Phone:815-348-9281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.030828122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist