Provider Demographics
NPI:1043051642
Name:VA SMILE FOUNDATION, INC.
Entity type:Organization
Organization Name:VA SMILE FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENYUATIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GASH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:757-927-7477
Mailing Address - Street 1:110 COLISEUM XING STE 5142
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5971
Mailing Address - Country:US
Mailing Address - Phone:757-927-7477
Mailing Address - Fax:757-654-3194
Practice Address - Street 1:12 MUSKET LN
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5345
Practice Address - Country:US
Practice Address - Phone:757-927-7477
Practice Address - Fax:757-654-3194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251B00000XAgenciesCase Management