Provider Demographics
NPI:1669671004
Name:HAINES, DONALD W (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:W
Last Name:HAINES
Suffix:
Gender:M
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:PO BOX 318
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:PA
Mailing Address - Zip Code:18444
Mailing Address - Country:US
Mailing Address - Phone:570-842-4515
Mailing Address - Fax:570-842-4515
Practice Address - Street 1:921 DRINKER TURNPIKE
Practice Address - Street 2:SUITE 19
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18444
Practice Address - Country:US
Practice Address - Phone:570-842-4515
Practice Address - Fax:570-842-4515
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO 23432L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014995290001Medicaid