1609089002 NPI number — DR DAMARIS BASTIAN GEN.DENT. LLC

Table of content: (NPI 1609089002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609089002 NPI number — DR DAMARIS BASTIAN GEN.DENT. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR DAMARIS BASTIAN GEN.DENT. LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609089002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 DEVANT ST STE 404
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-884-5352
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 DEVANT ST STE 404
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-884-5352
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BASTIAN
Authorized Official First Name:
DAMARIS
Authorized Official Middle Name:
DERECE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-884-5352

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  5087 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1850870 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4334104830 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".