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General NPI Number Information
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NPI Number | 1336978188
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Entity Type | Individual
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Provider Name | RONEN MAVASHEV
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Gender | Male
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Dates
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Enumeration Date | 07/30/2024
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 55 E BROADWAY UNIT 1
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City | DERRY
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State | NH
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Zip | 03038-2401
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Country | US
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Telephone | 603-945-1287
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Fax |
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Provider Business Mailing Address
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Address Line | 55 E BROADWAY UNIT 1
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City | DERRY
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State | NH
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Zip | 03038-2401
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Country | US
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Telephone | 603-945-1287
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 110391
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 05159
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License Number State | NH
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