Provider Demographics
NPI:1104908227
Name:SMITH, CHARLOTTE ANNE (DMD)
Entity type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28119 N MAIN ST
Mailing Address - Street 2:STE A
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-7037
Mailing Address - Country:US
Mailing Address - Phone:257-626-2728
Mailing Address - Fax:257-626-2877
Practice Address - Street 1:28119 N MAIN ST
Practice Address - Street 2:STE A
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-7037
Practice Address - Country:US
Practice Address - Phone:257-626-2728
Practice Address - Fax:257-626-2877
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL44671223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL96999OtherBLUE CROSS