Healthcare Provider Details

I. General information

NPI: 1518546472
Provider Name (Legal Business Name): RAHUL RAJAGOPALAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 06/02/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 S 27TH ST
FRANKLIN WI
53132-8045
US

IV. Provider business mailing address

1900 W POLK ST UNIT 611
CHICAGO IL
60612-3723
US

V. Phone/Fax

Practice location:
  • Phone: 414-435-0787
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.033095
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number100254
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: