Provider Demographics
NPI:1134137755
Name:DAUGHTRY, CHARLES STEVEN (D M D)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEVEN
Last Name:DAUGHTRY
Suffix:
Gender:M
Credentials:D M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 SADDLECREEK TRL
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-6005
Mailing Address - Country:US
Mailing Address - Phone:205-980-8458
Mailing Address - Fax:
Practice Address - Street 1:4515 SOUTHLAKE PKWY
Practice Address - Street 2:STE 101
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35244-3317
Practice Address - Country:US
Practice Address - Phone:205-988-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLN034071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL045814OtherUNITED CONCORDIA
AL91579OtherBLUE CROSS BLUE SHILED