Provider Demographics
NPI:1255665667
Name:MARK D. THEBAUT, D.D.S, PC DBA
Entity Type:Organization
Organization Name:MARK D. THEBAUT, D.D.S, PC DBA
Other - Org Name:GWINNETT CHILDRENS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DENNY
Authorized Official - Last Name:THEBAUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-990-6301
Mailing Address - Street 1:609 BEAVER RUIN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:770-925-3300
Mailing Address - Fax:770-925-3302
Practice Address - Street 1:609 BEAVER RUIN RD
Practice Address - Street 2:SUITE A
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-925-3300
Practice Address - Fax:770-925-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA151700972AMedicaid
GA232076497AMedicaid
GA177273740DMedicaid
GA149199935AMedicaid
GA000185875EMedicaid
GA591447276BMedicaid