Provider Demographics
NPI:1730215393
Name:CV SMITH SC
Entity type:Organization
Organization Name:CV SMITH SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:V
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:608-989-2771
Mailing Address - Street 1:PO BOX 816
Mailing Address - Street 2:
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 STREET
Practice Address - Street 2:
Practice Address - City:BLAIR
Practice Address - State:WI
Practice Address - Zip Code:54616
Practice Address - Country:US
Practice Address - Phone:608-989-2771
Practice Address - Fax:608-989-9626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001157-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
831108OtherUNITED CONCORDIA
WI33592400Medicaid
WI=========017OtherBLUE CROSS BLUE SHIELD