Provider Demographics
NPI:1235985565
Name:HAIRSTON, BRIANNA NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:BRIANNA
Middle Name:NICOLE
Last Name:HAIRSTON
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 1:300 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4210
Mailing Address - Country:US
Mailing Address - Phone:919-444-1190
Mailing Address - Fax:
Practice Address - Street 1:6783 VETERANS PKWY BLDG 4
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3254
Practice Address - Country:US
Practice Address - Phone:706-321-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN123487122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program