Provider Demographics
NPI:1760665046
Name:RAJAGOPAL, RAJIV (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAJIV
Middle Name:
Last Name:RAJAGOPAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 E MCANDREWS RD # A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5334
Mailing Address - Country:US
Mailing Address - Phone:541-779-3781
Mailing Address - Fax:541-779-6523
Practice Address - Street 1:1625 E MCANDREWS RD # A
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5334
Practice Address - Country:US
Practice Address - Phone:541-779-3781
Practice Address - Fax:541-779-6523
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR77561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233335Medicaid
ORU85045Medicare UPIN
OR108543Medicare Oscar/Certification