MEDICARE: IRENA VAKSMAN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	57715	CA

General Provider Information

NPI Number	:	1114017977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRENA VAKSMAN DDS

Provider Business Mailing Address
First Line	:	1241 MISSION RD
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-1397
Country	:	US
Telephone Number	:	650-588-3710
Fax Number	:

Provider Business Practice Location Address
First Line	:	1241 MISSION RD
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-1397
Country	:	US
Telephone Number	:	650-588-3710
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	06/16/2026

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