Provider Demographics
NPI:1609089002
Name:DR DAMARIS BASTIAN GEN.DENT. LLC
Entity Type:Organization
Organization Name:DR DAMARIS BASTIAN GEN.DENT. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAMARIS
Authorized Official - Middle Name:DERECE
Authorized Official - Last Name:BASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-884-5352
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1850870Medicaid
LA4334104830OtherBLUE CROSS BLUE SHEILD