Provider Demographics
NPI:1154448850
Name:PLATINUM DENTAL OF LILBURN
Entity Type:Organization
Organization Name:PLATINUM DENTAL OF LILBURN
Other - Org Name:PLATINUM DENTAL LILBURN, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:THEBAUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-709-0000
Mailing Address - Street 1:609 BEAVER RUIN RD NW STE A
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3401
Mailing Address - Country:US
Mailing Address - Phone:770-709-0000
Mailing Address - Fax:770-925-3302
Practice Address - Street 1:609 BEAVER RUIN RD NW STE A
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3401
Practice Address - Country:US
Practice Address - Phone:770-709-0000
Practice Address - Fax:770-925-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA91131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty