MEDICARE: DR. CHARLES WILLIAM SMITH DDS

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	9387	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5011757	OTHER	MN	MD TAX ID
2	555133	OTHER	MN	MN DEPT OF HEALTH

General Provider Information

NPI Number	:	1982697843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES WILLIAM SMITH DDS

Provider Business Mailing Address
First Line	:	5039 HIGHWAY 52 NORTH FRONTAGE ROAD
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55901
Country	:	US
Telephone Number	:	507-282-7905
Fax Number	:

Provider Business Practice Location Address
First Line	:	5039 HWY 52N W. FRONTAGE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55901
Country	:	US
Telephone Number	:	507-282-7905
Fax Number	:	507-286-9382

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

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	12/30/2015

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