Healthcare Provider Details

I. General information

NPI: 1114017977
Provider Name (Legal Business Name): IRENA VAKSMAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 MISSION RD
SOUTH SAN FRANCISCO CA
94080-1397
US

IV. Provider business mailing address

1241 MISSION RD
SOUTH SAN FRANCISCO CA
94080-1397
US

V. Phone/Fax

Practice location:
  • Phone: 650-588-3710
  • Fax:
Mailing address:
  • Phone: 650-588-3710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: