Provider Demographics
NPI:1134290901
Name:SMITH, CHARLES A
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:SMITH
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 1:5875 LANDERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-6511
Mailing Address - Country:US
Mailing Address - Phone:800-487-4867
Mailing Address - Fax:216-593-7533
Practice Address - Street 1:5875 LANDERBROOK DR
Practice Address - Street 2:
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-6511
Practice Address - Country:US
Practice Address - Phone:800-487-4867
Practice Address - Fax:216-593-7533
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice