Provider Demographics
NPI:1518218353
Name:BASTIAN, DAMARIS DERECE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAMARIS
Middle Name:DERECE
Last Name:BASTIAN
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 1:101 DEVANT ST STE 404
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2713
Mailing Address - Country:US
Mailing Address - Phone:678-884-5352
Mailing Address - Fax:
Practice Address - Street 1:101 DEVANT ST STE 404
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2713
Practice Address - Country:US
Practice Address - Phone:678-884-5352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0154821223G0001X
LA50871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1850870Medicaid