Provider Demographics
NPI:1770273948
Name:KANE, CHARLES SHERWOOD
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:SHERWOOD
Last Name:KANE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9159 FRANKTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:FRANKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23354
Mailing Address - Country:US
Mailing Address - Phone:757-442-4819
Mailing Address - Fax:
Practice Address - Street 1:9197 FRANKTOWN RD
Practice Address - Street 2:
Practice Address - City:FRANKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23354-2254
Practice Address - Country:US
Practice Address - Phone:757-442-4819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418826122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program