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General NPI Number Information
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NPI Number | 1396106142
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Entity Type | Organization
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Legal Business Name | TEBO DENTISTRY FOR KIDS MARIETTA LLC
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Dates
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Enumeration Date | 03/08/2016
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Last Update Date | 03/08/2016
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Provider Practice Location Address
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Address Line | 2155 POST OAK TRITT RD SUITE 450
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City | MARIETTA
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State | GA
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Zip | 30062-8620
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Country | US
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Telephone | 770-925-3300
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1953
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City | LILBURN
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State | GA
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Zip | 30048-1953
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. MARK DENNY THEBAUT
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Credential | D.D.S.
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Telephone | 770-925-3300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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