Provider Demographics
NPI:1326428558
Name:HAIRSTON, LEAH RAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:RAE
Last Name:HAIRSTON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 LEE ST W
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2342
Mailing Address - Country:US
Mailing Address - Phone:304-342-0146
Mailing Address - Fax:
Practice Address - Street 1:112 LEE ST W
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2342
Practice Address - Country:US
Practice Address - Phone:304-342-0146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005399Medicaid