Provider Demographics
NPI:1184228041
Name:RASLAN, DEEMA
Entity Type:Individual
Prefix:
First Name:DEEMA
Middle Name:
Last Name:RASLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 COURTYARD DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3163
Mailing Address - Country:US
Mailing Address - Phone:857-770-8424
Mailing Address - Fax:
Practice Address - Street 1:307 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2700
Practice Address - Country:US
Practice Address - Phone:706-884-3263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN016162T122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist