Healthcare Provider Details

I. General information

NPI: 1043051642
Provider Name (Legal Business Name): VA SMILE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MUSKET LN
HAMPTON VA
23666-5345
US

IV. Provider business mailing address

110 COLISEUM XING STE 5142
HAMPTON VA
23666-5971
US

V. Phone/Fax

Practice location:
  • Phone: 757-927-7477
  • Fax: 757-654-3194
Mailing address:
  • Phone: 757-927-7477
  • Fax: 757-654-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. KENYUATIA LYNN GASH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LCSW
Phone: 757-927-7477