Provider Demographics
NPI:1003919903
Name:SMITH, CHARLES A (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 GOVERNMENT STREET
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-872-3333
Mailing Address - Fax:228-872-9877
Practice Address - Street 1:2810 GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5642
Practice Address - Country:US
Practice Address - Phone:228-872-3333
Practice Address - Fax:228-872-9877
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1684751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice