MEDICARE: DR. CHARLES V SMITH D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5001157	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740203553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES V SMITH D.D.S.

Provider Business Mailing Address
First Line	:	PO BOX 816
Second Line	:	217 E. 4TH ST
City	:	BLAIR
State	:	WI
Zip	:	54616-0816
Country	:	US
Telephone Number	:	608-989-2771
Fax Number	:	608-989-9626

Provider Business Practice Location Address
First Line	:	217 E. 4TH ST
Second Line	:
City	:	BLAIR
State	:	WI
Zip	:	54616-0816
Country	:	US
Telephone Number	:	608-989-2771
Fax Number	:	608-989-9626

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	05/29/2013

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