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General NPI Number Information
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NPI Number | 1407397516
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Entity Type | Organization
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Legal Business Name | HAIRSTON FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/09/2017
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Last Update Date | 03/09/2017
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Provider Practice Location Address
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Address Line | 255 WASHINGTON ST
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City | RAVENSWOOD
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State | WV
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Zip | 26164-1874
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Country | US
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Telephone | 304-273-5301
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Fax |
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Provider Business Mailing Address
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Address Line | 255 WASHINGTON ST
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City | RAVENSWOOD
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State | WV
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Zip | 26164-1874
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Country | US
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Telephone | 304-273-5301
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | DR. LEAH RAE HAIRSTON
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Credential | DDS
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Telephone | 304-542-7860
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | WV4152
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License Number State | WV
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