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General NPI Number Information
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NPI Number | 1962634543
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Entity Type | Organization
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Legal Business Name | PLATINUM DENTAL GROUP LILBURN LLC
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Dates
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Enumeration Date | 08/17/2009
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Last Update Date | 08/17/2009
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Provider Practice Location Address
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Address Line | 609 BEAVER RUIN RD. STE A
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City | LILBURN
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State | GA
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Zip | 30047
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Country | US
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Telephone | 770-709-0000
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Fax | 770-925-3302
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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 | 770-709-0000
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Fax | 770-925-3302
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | MR. MARK DENNY THEBAUT
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Credential | DDS
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Telephone | 678-990-6301
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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 | DN009113
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License Number State | GA
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