Organization
PLATINUM DENTAL GROUP LILBURN LLC
Active
Parent organization
PLATINUM DENTAL GROUP LILBURN LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
PLATINUM DENTAL GROUP LILBURN LLC
Authorized official
MR. MARK DENNY THEBAUT DDS (OWNER/DENTIST)
(678) 990-6301
Entity
Organization
Contact information
Practice address
609 BEAVER RUIN RD., STE A, LILBURN, GA 30047
(770) 709-0000
(770) 925-3302
Mailing address
PO BOX 1953, LILBURN, GA 30048-1953
(770) 709-0000
(770) 925-3302
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
DN009113
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
151700972B
—
GA
Enumeration date
08/17/2009
Last updated
08/17/2009
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