Organization
PLATINUM DENTAL GROUP LILBURN, 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
609 BEAVER RUIN RD, SUITE A, LILBURN, GA 30047
(770) 709-0000
(770) 925-3302
Mailing address
609 BEAVER RUIN RD, SUITE A, LILBURN, GA 30047
(770) 709-0000
(770) 925-3302
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
—
—
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000185875J
—
GA
05
—
149199935B
—
GA
05
—
151700972B
—
GA
05
—
232076497B
—
GA
05
—
591447276C
—
GA
05
—
832239687A
—
GA
Enumeration date
10/01/2009
Last updated
10/01/2009
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