Provider Demographics
NPI:1659085637
Name:TEBO DENTISTRY FOR KIDS CUMMING LLC
Entity Type:Organization
Organization Name:TEBO DENTISTRY FOR KIDS CUMMING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
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:30048-1953
Mailing Address - Country:US
Mailing Address - Phone:770-925-3300
Mailing Address - Fax:
Practice Address - Street 1:1725 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-8201
Practice Address - Country:US
Practice Address - Phone:770-925-3300
Practice Address - Fax:770-925-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental