Provider Demographics
NPI:1770183915
Name:ISACHAROV, RONEN
Entity Type:Individual
Prefix:
First Name:RONEN
Middle Name:
Last Name:ISACHAROV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14722 HOOVER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2140
Mailing Address - Country:US
Mailing Address - Phone:347-592-0056
Mailing Address - Fax:
Practice Address - Street 1:14722 HOOVER AVE FL 2
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-2140
Practice Address - Country:US
Practice Address - Phone:347-592-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY062416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program