Provider Demographics
NPI:1801204292
Name:MYSORE RAJAGOPAL, SOWMYA (DDS)
Entity Type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:MYSORE RAJAGOPAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WALTON DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76705-2468
Mailing Address - Country:US
Mailing Address - Phone:408-505-4155
Mailing Address - Fax:
Practice Address - Street 1:2180 W KIMBERLY RD SPC 8
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-5368
Practice Address - Country:US
Practice Address - Phone:855-505-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA092241223G0001X
CADDS636911223G0001X
IL019.0304711223G0001X
TX305361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicaid
IA1598759029Medicaid