Provider Demographics
NPI:1740203553
Name:SMITH, CHARLES V (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:V
Last Name:SMITH
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:PO BOX 816
Mailing Address - Street 2:217 E. 4TH ST
Mailing Address - City:BLAIR
Mailing Address - State:WI
Mailing Address - Zip Code:54616-0816
Mailing Address - Country:US
Mailing Address - Phone:608-989-2771
Mailing Address - Fax:608-989-9626
Practice Address - Street 1:217 E. 4TH ST
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616-0816
Practice Address - Country:US
Practice Address - Phone:608-989-2771
Practice Address - Fax:608-989-9626
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50011571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33592400Medicaid