Provider Demographics
NPI:1679618599
Name:HAIRE, WENONAH (DMD)
Entity type:Individual
Prefix:DR
First Name:WENONAH
Middle Name:
Last Name:HAIRE
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 1:1387 MEADOW LAKES RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-9098
Mailing Address - Country:US
Mailing Address - Phone:803-328-8037
Mailing Address - Fax:
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5324
Practice Address - Country:US
Practice Address - Phone:803-324-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0022681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC002268Medicaid