Healthcare Provider Details

I. General information

NPI: 1770273948
Provider Name (Legal Business Name): CHARLES SHERWOOD KANE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 12/12/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9197 FRANKTOWN RD
FRANKTOWN VA
23354-2254
US

IV. Provider business mailing address

9159 FRANKTOWN ROAD
FRANKTOWN VA
23354
US

V. Phone/Fax

Practice location:
  • Phone: 757-442-4819
  • Fax:
Mailing address:
  • Phone: 757-442-4819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418826
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: