Individual
DR. MARK D THEBAUT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
609 BEAVER RUIN RD NW, LILBURN, GA 30047-3401
(770) 925-3300
(770) 925-3302
Mailing address
609 BEAVER RUIN RD NW, LILBURN, GA 30047-3401
(770) 925-3300
(770) 925-3302
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
9113
GA
Other
Enumeration date
09/01/2006
Last updated
07/09/2007
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