Healthcare Provider Details

I. General information

NPI: 1629581715
Provider Name (Legal Business Name): IDEAL SMILE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2017
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8904 W BROAD ST STE 202
HENRICO VA
23294
US

IV. Provider business mailing address

8904 W BROAD ST STE 202
HENRICO VA
23294
US

V. Phone/Fax

Practice location:
  • Phone: 804-716-5430
  • Fax:
Mailing address:
  • Phone: 804-716-5430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401412655
License Number StateVA

VIII. Authorized Official

Name: AHMED ELKHARASHI
Title or Position: OWNER
Credential: DOCTOR
Phone: 804-716-5430