Provider Demographics
NPI:1114017977
Name:VAKSMAN, IRENA (DDS)
Entity Type:Individual
Prefix:
First Name:IRENA
Middle Name:
Last Name:VAKSMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 SUTTER ST RM 2307
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4209
Mailing Address - Country:US
Mailing Address - Phone:415-404-6644
Mailing Address - Fax:415-404-7942
Practice Address - Street 1:450 SUTTER ST RM 2307
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4209
Practice Address - Country:US
Practice Address - Phone:415-404-6644
Practice Address - Fax:415-404-7942
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV49121223G0001X
CA57715122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist