Organization
PLATINUM DENTAL GROUP GAINESVILLE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MARK DENNY THEBAUT DDS (OWNER/DENTIST)
(678) 990-6301
Entity
Organization
Contact information
Practice address
3535 THOMPSON BRIDGE RD, GAINESVILLE, GA 30506
(770) 534-5374
(770) 534-5591
Mailing address
3535 THOMPSON BRIDGE RD, GAINESVILLE, GA 30506
(770) 534-5374
(770) 534-5591
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
—
—
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000185875H
—
GA
05
—
149199935C
—
GA
05
—
151700972D
—
GA
05
—
177273740C
—
GA
05
—
232076497C
—
GA
05
—
591447276D
—
GA
Enumeration date
10/01/2009
Last updated
10/01/2009
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