Healthcare Provider Details

I. General information

NPI: 1083145544
Provider Name (Legal Business Name): STEPHANIE MAYORGA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2017
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 KEITH ST
SAN FRANCISCO CA
94124-3231
US

IV. Provider business mailing address

79 ATHENS ST
SAN FRANCISCO CA
94112-1601
US

V. Phone/Fax

Practice location:
  • Phone: 628-217-5500
  • Fax: 415-822-3620
Mailing address:
  • Phone: 415-359-8894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number101242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: