Provider Demographics
NPI:1568998466
Name:SMITH, CHARLES (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 QUIG YOUNGS RD
Mailing Address - Street 2:
Mailing Address - City:MORELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30259-3048
Mailing Address - Country:US
Mailing Address - Phone:678-576-0425
Mailing Address - Fax:
Practice Address - Street 1:2712 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1330
Practice Address - Country:US
Practice Address - Phone:678-576-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0155641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice