Individual
DR. BASU BANSTOLA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2315 BROCKETT RD, TUCKER, GA 30084-4412
(770) 934-1698
Mailing address
PO BOX 2635, TUCKER, GA 30085-2635
(404) 704-2088
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
DS040169
PA
Other
Enumeration date
09/22/2014
Last updated
12/01/2021
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