Provider Demographics
NPI:1871625954
Name:RAJAGOPAL, ILAYA RAMANAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ILAYA
Middle Name:RAMANAN
Last Name:RAJAGOPAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-4738
Mailing Address - Country:US
Mailing Address - Phone:301-393-3447
Mailing Address - Fax:301-393-3463
Practice Address - Street 1:24 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-4738
Practice Address - Country:US
Practice Address - Phone:301-393-3447
Practice Address - Fax:301-393-3463
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL5201223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLL520OtherLIC REG CERT NO
MD004643400Medicare ID - Type UnspecifiedPROVIDER #