Organization
DR DAMARIS BASTIAN GEN.DENT. LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAMARIS DERECE BASTIAN DDS (OWNER)
(678) 884-5352
Entity
Organization
Contact information
Practice address
101 DEVANT ST STE 404, FAYETTEVILLE, GA 30214-2713
(678) 884-5352
Mailing address
101 DEVANT ST STE 404, FAYETTEVILLE, GA 30214-2713
(678) 884-5352
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
5087
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1850870
—
LA
01
—
4334104830
BLUE CROSS BLUE SHEILD
LA
Enumeration date
05/08/2007
Last updated
11/08/2021
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