=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871970947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAGHAV KHANDELWAL D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2015
-----------------------------------------------------
Last Update Date | 08/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1855 SAN MIGUEL DR STE 25
-----------------------------------------------------
City | WALNUT CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94596-5298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-437-4800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70101 VIA VICENZA
-----------------------------------------------------
City | SAN RAMON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94583-3132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-650-7618
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 63762
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------