Provider Demographics
NPI:1457557852
Name:SMITH, CHARLES DOUGLAS (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:C
Other - Middle Name:DOUGLAS
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1609 WEST MAIN STREET
Mailing Address - Street 2:STE 202
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-793-1500
Mailing Address - Fax:334-792-9647
Practice Address - Street 1:1609 WEST MAIN STREET
Practice Address - Street 2:STE 202
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301
Practice Address - Country:US
Practice Address - Phone:334-793-1500
Practice Address - Fax:334-792-9647
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3365122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist