Healthcare Provider Details

I. General information

NPI: 1306525944
Provider Name (Legal Business Name): IVAN RUVINOV DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 E STILL CIR
MESA AZ
85206-3618
US

IV. Provider business mailing address

1666 S DOBSON RD APT 3075
MESA AZ
85202-1610
US

V. Phone/Fax

Practice location:
  • Phone: 480-265-8005
  • Fax: 623-223-7073
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: