Provider Demographics
NPI:1568956308
Name:MANOSOV, RONEN (DDS)
Entity Type:Individual
Prefix:
First Name:RONEN
Middle Name:
Last Name:MANOSOV
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 1:773 HAVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1232
Mailing Address - Country:US
Mailing Address - Phone:408-242-5010
Mailing Address - Fax:
Practice Address - Street 1:4646 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-1329
Practice Address - Country:US
Practice Address - Phone:650-383-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1025291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice