Provider Demographics
NPI:1083172035
Name:TEBO DENTISTRY FOR KIDS PEACHTREE CORNERS, LLC
Entity Type:Organization
Organization Name:TEBO DENTISTRY FOR KIDS PEACHTREE CORNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:THEBAUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-925-3300
Mailing Address - Street 1:PO BOX 1953
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6460 SPALDING DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092
Practice Address - Country:US
Practice Address - Phone:770-925-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental