Healthcare Provider Details

I. General information

NPI: 1336978188
Provider Name (Legal Business Name): RONEN MAVASHEV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E BROADWAY UNIT 1
DERRY NH
03038-2401
US

IV. Provider business mailing address

55 E BROADWAY UNIT 1
DERRY NH
03038-2401
US

V. Phone/Fax

Practice location:
  • Phone: 603-945-1287
  • Fax:
Mailing address:
  • Phone: 603-945-1287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number110391
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number05159
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: