Provider Demographics
NPI:1699851089
Name:SMURTHWAITE, CHARLES BRENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BRENT
Last Name:SMURTHWAITE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 DARBY CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4928
Mailing Address - Country:US
Mailing Address - Phone:916-435-4005
Mailing Address - Fax:
Practice Address - Street 1:6000 FAIRWAY DR
Practice Address - Street 2:SUITE 8
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4244
Practice Address - Country:US
Practice Address - Phone:916-632-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA478011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice